Datasets:

HoangHa

/

medical-domain

like 0

{ "text": "PREOPERATIVE DIAGNOSIS:, Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1. Pelvic pain.,2. Pelvic endometriosis.,3. Pelvic adhesions.,PROCEDURE PERFORMED:,1. Laparoscopy.,2. Harmonic scalpel ablation of endometriosis.,3. Lysis of adhesions.,4. Cervical dilation.,ANESTHESIA: ,General.,SPECIMEN: ,Peritoneal biopsy.,ESTIMATED BLOOD LOSS:, Scant.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses. Laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa. There are adhesions involving the right ovary to the anterior abdominal wall and the bowel. There are also adhesions from the omentum to the anterior abdominal wall near the liver. The uterus and ovaries appear within normal limits other than the adhesions. The left fallopian tube grossly appeared within normal limits. The right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized. There was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac. There was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,PROCEDURE: ,The patient was taken in the operating room and generalized anesthetic was administered. She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. After exam under anesthetic, weighted speculum was placed in the vagina. The anterior lip of the cervix was grasped with vulsellum tenaculum. The uterus was sounded and then was serially dilated with Hank dilators to a size 10 Hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix. At this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen. An approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife. The superior aspect of the umbilicus was grasped with a towel clamp. The abdomen was tented up and a Veress needle inserted through this incision. When the Veress needle was felt to be in place, deep position was checked by placing saline in the needle. This was seen to freely drop in the abdomen so it was connected to CO2 gas. Again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting. The abdomen was then insufflated to an adequate distention. Once an adequate distention was reached, the CO2 gas was disconnected. The Veress needle was removed and a size #11 step trocar was placed. Next, the laparoscope was inserted through this port. The medial port was connected to CO2 gas. Next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis. Through this, a Veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed. Next, a grasper was placed through the suprapubic port. This was used to grasp the bowel that was adhesed to the right ovary and the Harmonic scalpel was then used to lyse these adhesions. Bowel was carefully examined afterwards and no injuries or bleeding were seen. Next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the Harmonic scalpel and this was done without difficulty. There was a small amount of bleeding from the anterior abdominal wall peritoneum. This was ablated with the Harmonic scalpel. The Harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac. Both of these areas were seen to be hemostatic. Next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac. This was sent to pathology. Next, the pelvis was copiously irrigated with the Nezhat dorsi suction irrigator and the irrigator was removed. It was seen to be completely hemostatic. Next, the two size #5 ports were removed under direct visualization. The camera was removed. The abdomen was desufflated. The size #11 introducer was replaced and the #11 port was removed.,Next, all the ports were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion. The incisions were dressed with Steri-Strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with Darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check." }

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

{ "text_length": 4781 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1. Painful enlarged navicula, right foot.,2. Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1. Partial tarsectomy navicula, right foot.,2. Partial metatarsectomy, right foot.,HISTORY: ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time.,PROCEDURE: ,An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap. Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal. Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was then inflated to 250 mmHg. The foot was lowered as well as the operating table. The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge. Attention was then directed to the navicular region on the right foot. The area was palpated until the bony prominence was noted. A curvilinear incision was made over the area of bony prominence. At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site. The incision was then deepened with #15 blade. All vessels encountered were ligated for hemostasis. The dissection was carried down to the level of the capsule and periosteum. A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone. The periosteum and the capsule were then reflected from the navicular bone at this time. A bony prominence was noted both medially and plantarly to the navicular bone. An osteotome and mallet were then used to resect the enlarged portion of the navicular bone. After resection with an osteotome there was noted to be a large plantar shelf. The surrounding soft tissues were then freed from this plantar area. Care was taken to protect the attachments of the posterior tibial tendon as much as possible. Only minimal resection of its attachment to the fiber was performed in order to expose the bone. Sagittal saw was then used to resect the remaining plantar medial prominent bone. The area was then smoothed with reciprocating rasp until no sharp edges were noted. The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted. The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl. The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal. There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal. Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal. The incision was then deepened with #15 blade. Care was taken to preserve the extensor tendon. The incision was then created over the capsule and periosteum of the fifth metatarsal head. Capsule and periosteum were reflected both dorsally, laterally, and plantarly. At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal. A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp. The area was inspected for the remaining bony prominences and none was noted. The area was flushed with copious amounts of sterile saline. The capsule and periosteum were then reapproximated with #3-0 Vicryl. Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line. Running #5-0 subcutaneous stitch was then performed. Steri-Strips were applied to both surgical sites. Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban. The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications. The patient was transferred to the PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated. The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise." }

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

{ "text_length": 5642 }

{ "text": "PAST MEDICAL HISTORY:, Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:, PENICILLIN.,CURRENT MEDICATIONS:, Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: ,The patient is a non-smoker. No alcohol abuse. The patient is married with no children.,REVIEW OF SYSTEMS:, Significant for an old CVA.,PHYSICAL EXAMINATION:, The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air. HEENT: Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm. Abdomen: Soft and nontender. No organomegaly or masses. Extremities: No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1. Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2. Old CVA with left hemiparesis.,3. Oropharyngeal dysphagia.,4. Diabetes.,PLAN:, At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me." }

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

{ "text_length": 1844 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:, Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1. Left neck mass biopsy.,2. Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:, After obtaining an informed, the patient was taken to the operating room where a time-out process was followed. Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room. Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation. The neck was prepped and draped in the usual fashion. I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap. Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass. The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck. A wedge sample was sent to Pathology for frozen section. At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen. Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements. This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface. There, there were some attachments to branches of the external carotid artery, which had to be suture ligated. At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck. This worked out quite nicely. The external jugular vein was out of the way, so initially we did not deal with it. We proceeded to tackle the area III and extended into II-A. When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise. Also, I felt that the submaxillary gland was enlarged. At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle. At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination. Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen. Hemostasis was revised and found to be adequate. The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap. The flap was replaced in its position. A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin. I would like to mention that also the facial vein was excised and the external jugular vein was ligated. It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it. A pressure dressing was applied.,The patient tolerated the procedure well. Estimated blood loss was no more than 100 mL. The patient was extubated in the operating room and sent for recovery." }

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

{ "text_length": 4282 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:, Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:, General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia. A #21-French cystourethroscope was inserted into the bladder. Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice. No other lesions were noted. Using a cold punch biopsy forceps, a random biopsy was obtained. The entire area was electrofulgurated using the Bugbee electrode. The patient tolerated the procedure well and left the operating room in satisfactory condition." }

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

{ "text_length": 928 }

{ "text": "NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,INDICATION:, Recurrent angina. History of coronary disease.,TECHNICAL PROCEDURE: , Standard Judkins, right groin.,CATHETERS USED:, 6-French pigtail, 6-French JL4, 6-French JR4.,ANTICOAGULATION: , 2000 of heparin, 300 of Plavix, was begun on Integrilin.,COMPLICATIONS: , None.,STENT: , For stenting we used a 6-French left Judkins guide. Stent was a 275 x 13 Zeta.,DESCRIPTION OF PROCEDURE: , I reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. All questions were answered and the patient decided to proceed.,HEMODYNAMIC DATA: , Aortic pressure was within physiologic range. There was no significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram: Left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. Right coronary artery: Dominant. There was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. Left coronary artery: The left main coronary artery showed insignificant disease. The circumflex arose, showed about 30% proximally. Left anterior descending arose and the previously placed stent was perfectly patent. There was a large diagonal branch which showed 90% stenosis in its proximal portion. There was a lesion in the 30% to 40% range even more proximal.,I reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. He desired that we intervene.,Successful stenting of the left anterior descending, diagonal. The guide was placed in the left main. We easily crossed the lesion in the diagonal branch of the left anterior descending. We advanced, applied and post-dilated the 275 x 13 stent. Final angiography showed 0% residual at the site of previous 90% stenosis. The more proximal 30% to 40% lesion was unchanged.,CONCLUSION,1. Successful stenting of the left anterior descending/diagonal. Initially there was 90% in the diagonal after stenting. There was 0% residual. There was a lesion a bit more proximal in the 40% range.,2. Left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. Ejection fraction and wall motion are normal.,PLAN: , We have stented the culprit lesion. The patient will receive a course of aspirin, Plavix, Integrilin, and statin therapy. We used 6-French Angio-Seal in the groin. All questions have been answered. I have discussed the possibility of restenosis, need for further procedures." }

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

{ "text_length": 2919 }

{ "text": "PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. The preparation was poor, but mucosa was visible after lavage and suction. Small lesions might have been missed in certain places, but no large lesions are likely to have been missed. The mucosa was normal, was visualized. In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing. Biopsies were taken from the rectal wall to look for microscopic changes. The anal sphincter was considerably relaxed, with no tone and a gaping opening. The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum. No contraindications to consideration of a repair of the prolapse." }

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

{ "text_length": 1046 }

{ "text": "REASON FOR VISIT: , Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.,HISTORY OF PRESENT ILLNESS: , The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment.,The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night.,As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed.,In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts.,The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours.,The past medical history is notable for allergic rhinitis.,MEDICATIONS: , He is maintained on Flonase and denies much in the way of nasal symptoms.,ALLERGIES: , Molds.,FINDINGS: ,Vital signs: Blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and SaO2 is 99% on room air at rest.,The patient has adenoidal facies as noted previously.,Laboratories: The patient forgot to bring his smart card in for downloading today.,ASSESSMENT: , Moderate-to-severe sleep apnea. I have recommended the patient continue CPAP indefinitely. He will be sending me his smart card for downloading to determine his CPAP usage pattern. In addition, he will continue efforts to maintain his weight at current levels or below. Should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a CPAP.,PLANS: , In the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea. I have recommended that a fiberoptic ENT exam be performed to exclude adenoidal tissue that may be contributing to obstruction. He will be returning for routine followup in 6 months." }

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

{ "text_length": 3039 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS: ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital. This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam. Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. Minimal cartilaginous pieces were at the patellar tendon. He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department. A thigh high tourniquet was placed. He is prepped and draped in the usual sterile manner. Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes. Straight incision is carried down through skin and subcutaneous tissue anteriorly. Hemostasis was controlled via electrocoagulation. Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. The inferior pole was freshened up. Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. This was tied over the bony bridge superiorly. There was excellent reduction of the tendon to the patella. Interrupted running #1-Vicryl suture was utilized for over silk. A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum. There was excellent repair. Copious irrigation was carried out. Tourniquet was dropped and hemostasis controlled via electrocoagulation. Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing. Digits were warm and no brawny pulses present at the end of the case. The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion. He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair." }

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

{ "text_length": 2798 }

{ "text": "INDICATION: , Paroxysmal atrial fibrillation.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 55-year-old white female with multiple myeloma. She is status post chemotherapy and autologous stem cell transplant. Latter occurred on 02/05/2007. At that time, she was on telemetry monitor and noticed to be in normal sinus rhythm.,As part of study protocol for investigational drug for prophylaxis against mucositis, she had electrocardiogram performed on 02/06/2007. This demonstrated underlying rhythm of atrial fibrillation with rapid ventricular response at 125 beats per minute. She was subsequently transferred to telemetry for observation. Cardiology consultation was requested. Prior to formal consultation, the patient did have an echocardiogram performed on 02/06/2007, which showed a structurally normal heart with normal left ventricular (LV) systolic function, ejection fraction of 60%, aortic sclerosis without stenosis, a trivial pericardial effusion with no evidence for immunocompromise and mild tricuspid regurgitation with normal pulmonary atrial pressures. Overall, essentially normal heart.,At the time of my evaluation, the patient felt somewhat jittery and nervous, but otherwise asymptomatic.,PAST MEDICAL HISTORY:, Multiple myeloma, diagnosed in June of 2006, status post treatment with thalidomide and Coumadin. Subsequently, with high-dose chemotherapy followed by autologous stem cell transplant.,PAST SURGICAL HISTORY: , Cosmetic surgery of the nose and forehead.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,CURRENT MEDICATIONS,1. Acyclovir 400 mg p.o. b.i.d.,2. Filgrastim 300 mcg subcutaneous daily.,3. Fluconazole 200 mg daily.,4. Levofloxacin 250 mg p.o. daily.,5. Pantoprazole 40 mg daily.,6. Ursodiol 300 mg p.o. b.i.d.,7. Investigational drug is directed ondansetron 24 mg p.r.n.,FAMILY HISTORY: , Unremarkable. Father and mother both alive in their mid 70s. Father has an unspecified heart problem and diabetes. Mother has no significant medical problems. She has one sibling, a 53-year-old sister, who has a pacemaker implanted for unknown reasons.,SOCIAL HISTORY: , The patient is married. Has four adult children. Good health. She is a lifetime nonsmoker, social alcohol drinker.,REVIEW OF SYSTEMS: , Prior to treatment for her multiple myeloma, she was able to walk four miles nonstop. Currently, she has dyspnea on exertion on the order of one block. She denies any orthopnea or paroxysmal nocturnal dyspnea. She denies any lower extremity edema. She has no symptomatic palpitations or tachycardia. She has never had presyncope or syncope. She denies any chest pain whatsoever. She denies any history of coagulopathy or bleeding diathesis. Her oncologic disorder is multiple myeloma. Pulmonary review of systems is negative for recurrent pneumonias, bronchitis, reactive airway disease, exposure to asbestos or tuberculosis. Gastrointestinal (GI) review of systems is negative for known gastroesophageal reflux disease, GI bleed, and hepatobiliary disease. Genitourinary review of systems is negative for nephrolithiasis or hematuria. Musculoskeletal review of systems is negative for significant arthralgias or myalgias. Central nervous system (CNS) review of systems is negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke. Psychiatric review of systems is negative for known affective or cognitive disorders.,PHYSICAL EXAMINATION,GENERAL: This is a well-nourished, well-developed white female who appears her stated age and somewhat anxious.,VITAL SIGNS: She is afebrile at 97.4 degrees Fahrenheit with a heart rate ranging from 115 to 150 beats per minute, irregularly irregular. Respirations are 20 breaths per minute and blood pressure ranges from 90/59 to 107/68 mmHg. Oxygen saturation on room air is 94%.,HEENT: Benign being normocephalic and atraumatic. Extraocular motions are intact. Her sclerae are anicteric and conjunctivae are noninjected. Oral mucosa is pink and moist.,NECK: Jugular venous pulsations are normal. Carotid upstrokes are palpable bilaterally. There is no audible bruit. There is no lymphadenopathy or thyromegaly at the base of the neck.,CHEST: Cardiothoracic contour is normal. Lungs, clear to auscultation in all lung fields.,CARDIAC: Irregularly irregular rhythm and rate. S1, S2 without a significant murmur, rub, or gallop appreciated. Point of maximal impulse is normal, no right ventricular heave.,ABDOMEN: Soft with active bowel sounds. No organomegaly. No audible bruit. Nontender.,LOWER EXTREMITIES: Nonedematous. Femoral pulses were deferred.,LABORATORY DATA: , EKG, electrocardiogram showed underlying rhythm of atrial fibrillation with a rate of 125 beats per minute. Nonspecific ST-T wave abnormality is seen in the inferior leads only.,White blood cell count is 9.8, hematocrit of 30 and platelets 395. INR is 0.9. Sodium 136, potassium 4.2, BUN 43 with a creatinine of 2.0, and magnesium 2.9. AST and ALT 60 and 50. Lipase 343 and amylase 109. BNP 908. Troponin was less than 0.02.,IMPRESSION: , A middle-aged white female undergoing autologous stem cell transplant for multiple myeloma, now with paroxysmal atrial fibrillation.,Currently enrolled in a blinded study, where she may receive a drug for prophylaxis against mucositis, which has at least one reported incident of acceleration of preexisting tachycardia.,RECOMMENDATIONS,1. Atrial fibrillation. The patient is currently hemodynamically stable, tolerating her dysrhythmia. However, given the risk of thromboembolic complications, would like to convert to normal sinus rhythm if possible. Given that she was in normal sinus rhythm approximately 24 hours ago, this is relatively acute onset within the last 24 hours. We will initiate therapy with amiodarone 150 mg intravenous (IV) bolus followed by mg/minute at this juncture. If she does not have spontaneous cardioversion, we will consider either electrical cardioversion or anticoagulation with heparin within 24 hours from initiation of amiodarone.,As part of amiodarone protocol, please check TSH. Given her preexisting mild elevation of transaminases, we will follow LFTs closely, while on amiodarone.,2. Thromboembolic risk prophylaxis, as discussed above. No immediate indication for anticoagulation. If however she does not have spontaneous conversion within the next 24 hours, we will need to initiate therapy. This was discussed with Dr. X. Preference would be to run intravenous heparin with PTT of 45 during her thrombocytopenic nadir and initiation of full-dose anticoagulation once nadir is resolved.,3. Congestive heart failure. The patient is clinically euvolemic. Elevated BNP possibly secondary to infarct or renal insufficiency. Follow volume status closely. Follow serial BNPs.,4. Followup. The patient will be followed while in-house, recommendations made as clinically appropriate." }

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

{ "text_length": 6914 }

{ "text": "DIAGNOSIS:,1. Broad-based endocervical poly.,2. Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1. LEEP procedure of endocervical polyp.,2. Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered. The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in. Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures. A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted. The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition." }

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

{ "text_length": 1501 }

{ "text": "PRIMARY DISCHARGE DIAGNOSES:,1. Urinary tract infection.,2. Gastroenteritis with nausea and vomiting.,3. Upper gastrointestinal bleed likely secondary to gastritis.,4. Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1. Hypertension.,2. Gastroesophageal reflux disease.,3. Chronic atrial fibrillation.,4. Osteoporosis.,5. Valvular heart disease.,HOSPITAL COURSE SUMMARY: , The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection. Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis. The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk. The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,PAST MEDICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PAST SURGICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PHYSICAL EXAMINATION: ,VITAL SIGNS: At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,GENERAL: The patient is a thin built Caucasian female with no pallor, cyanosis or icterus. She is alert and oriented x3.,HEENT: No carotid bruits, JVD, lymphadenopathy or thyromegaly. Pupils are equally reactive to light and accommodation.,BACK AND EXTREMITY: Bilateral pitting edema and peripheral pulses are palpable. The patient has right hip brace/immobilizer.,HEART: Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2.,CHEST: Auscultation revealed bibasilar crackles.,ABDOMEN: Soft, nontender, no organomegaly and bowel sounds are present.,CNS: Nonfocal.,LABORATORY STUDIES: , WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8. Liver function tests were normal. The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set. Urinalysis revealed trace protein, trace blood, and 10-20 WBCs. Blood culture showed no growth till date. Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin.,Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia. Lung parenchyma was otherwise clear.,Right hip x-ray showed that the prosthesis was in satisfactory position. There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,DISCHARGE MEDICATIONS:,1. Aspirin 81 mg orally once daily.,2. Calcium with vitamin D two tablets orally once daily.,3. Nexium 40 mg orally once daily.,4. Multivitamins with minerals one capsule once daily.,5. Zoloft 25 mg orally once daily.,6. Norco 325/10 mg every 6-8 hours as needed for pain.,7. Systane ophthalmic solution two drops in both eyes every two hours as needed.,8. Herbal __________ by mouth everyday.,9. Macrodantin 100 mg orally every six hours for seven days.,ALLERGIES:, Penicillin.,PROGNOSIS: , Improved.,ASSESSMENT AND DISCHARGE PLAN: ,The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,PROBLEM #1: " }

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

{ "text_length": 3924 }

{ "text": "TITLE OF OPERATION:,1. Pars plana vitrectomy.,2. Pars plana lensectomy.,3. Exploration of exit wound.,4. Closure of perforating corneal scleral laceration involving uveal tissue.,5. Air-fluid exchange.,6. C3F8 gas.,7. Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall. He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:, General.,SPECIMEN:, None.,IMPLANTS:,1. Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2. Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife. All of their questions were answered. Informed consent was signed. The patient was brought into the operating room. A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye. After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery. A wire lid speculum was used to separate the eyelids of the left eye. A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon. The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried. A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors. Hemostasis was achieved with bipolar cautery. A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant. A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture. The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion. Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule. The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter. The vitreous was trimmed to the vitreous base. A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course. The exit wound was explored. No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps. The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression. No retinal breaks or defects were noted in the periphery. The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees. Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve. The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion. The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures. A 12% concentration of C3F8 gas was flushed through the eye. The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture. All of the sclerotomies were noted to be airtight. The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried. Subconjunctival injections of Ancef and Decadron were delivered inferotemporally. The lid speculum was removed. Pred-G ointment and atropine solution were applied to the ocular surface. The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well. There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure." }

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

{ "text_length": 5576 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus T8-T9.,OPERATION PERFORMED: , Thoracic right-sided discectomy at T8-T9.,BRIEF HISTORY AND INDICATION FOR OPERATION: , The patient is a 53-year-old female with a history of right thoracic rib pain related to a herniated nucleus pulposus at T8-T9. She has failed conservative measures and sought operative intervention for relief of her symptoms. For details of workup, please see the dictated operative report.,DESCRIPTION OF OPERATION: ,Appropriate informed consent was obtained and the patient was taken to the operating room and placed under general anesthetic. She was placed in a position of comfort on the operating table with all bony prominences and soft tissues well padded and protected. Second check was made prior to prepping and draping. Following this, we did needle localization with reviews of AP and lateral multiple times to make sure we had the T8-T9 level. We then made an approach through a midline incision and came out over the pars. We dissected down carefully to identify the pars. We then went on the outside of the pars and identified the foramen and then we took another series of x-rays to confirm the T8-T9 level. We did this under live fluoroscopy. We confirmed T8-T9 and then went ahead and took a Midas Rex and removed the superior portion of the pedicle overlying the outside of the disc and then worked our way downward removing portion of the transverse process as well. We found the edge of the disc and then worked our way and we were able to remove some of the disc material but then decided to go ahead and take down the pars. The pars was then drilled out. We identified the disc even further and found the disc herniation material that was under the spinal cord. We then took a combination of small pituitaries and removed the disc material without difficulty. Once we had disc material out, we went ahead and made a small cruciate incision in the disc space and entered the disc space in earnest removing more disc material making sure there is nothing free to herniate further. Once we had done that, we inspected up by the nerve root, found some more disc material there and removed that as well. We could trace the nerve root out freely and easily. We made sure there was no evidence of further disc material. We used an Epstein curette and placed a nerve hook under the nerve root. The Epstein curette removed some more disc material. Once we had done this, we were satisfied with the decompression. We irrigated the wound copiously to make sure there is no further disc material and then ready for closure. We did place some steroid over the nerve root and readied for closure. Hemostasis was meticulous. The wound was closed with #1 Vicryl suture for the fascial layer, 2 Vicryl suture for the skin, and Monocryl and Steri-Strips applied. Dressing was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:, 150 mL.,COMPLICATIONS: , None.,DISPOSITION:, To PACU in stable condition having tolerated the procedure well, to mobilize routinely when she is comfortable to go to her home." }

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

{ "text_length": 3241 }

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

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

{ "text_length": 4844 }

{ "text": "CC: , \"Five years ago, I stopped drinking and since that time, I have had severe depression. I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again. I started lithium three weeks ago.\",HPI: ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural. The patient has had one psychiatric hospitalization for seven days in April of 1999. The patient now presents with recurrent depressive symptoms for approximately four months. The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite. The patient states her sleep is normal and her ability to concentrate is normal. The patient states that last night she had an argument with her husband in which he threaten to divorce her. The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth. She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done. The patient reports that she has had increased tension with her husband as of recent. She notes that approximately a week ago she struck her husband several times. She states that he has never hit her but instead pushed her back after she was hitting him. She reports no history of abuse in the past. The patient identifies recent stressors as having ongoing conflict at work with her administrator with them \"cracking down on me.\" The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child. She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant. The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment. She states that she feels \"abandoned.\" The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband. The patient states she saw her therapist most recently last Friday. She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how. When asked for specifics of what she has learned from the therapy, the patient was unable to reply. It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation. The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization. The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night. At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed. When asked if she is suicidal at present, she states no. The patient does not want to go into the hospital. The patient also indicates at the end of the session she felt hopeful. The patient reports her current sleep is about eight hours per night. She states that longest she has been able to stay awake in the past has been 24 hours. She states that during periods where she feels up she sleeps perhaps six hours per night. The patient reports no spending sprees and no reports no sexual indiscretions. The patient states that her sexuality does increase when she is feeling better but not enormously so. The patient denies any history of delusions or hallucinations. The patient denies any psychosis. The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest. She states that more predominately she has depression. The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so. The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment. The patient indicates some satisfaction when she is called on her behavior \"I need to answer for my actions.\" The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized. Most typically, the patient will drink at least a bottle of wine per day. The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility. The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child. She states that she was disciplined primarily by her father with spankings. She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon. The patient has been seeing Dr. A for the past five years. Prior to that she was admitted to a hospital for her suicide attempt. The patient also has one short treatment experienced with the Day Treatment Program here in Portland. The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with. The patient, also as a child, had a history of cutting behaviors. The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY: ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results. Janet Green is her primary physician. The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years. She drank one bottle of wine per day as per HPI. History of drinking for approximately 25 years. The patient does not currently have a sponsor. The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44. Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage. He made a suicide attempt at age 17. The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem. He also has arthritis. The patient's mother is arthritic. She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College. The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely. She states she was unliked and unpopular child because she was \"shy\" and \"not smart enough.\" The patient denies having secrets. The patient reports that this is her second marriage, which has lasted two years. Her first marriage lasted I believe it was five years. The patient also had a relationship in recovery for four years, which ended after they went \"different directions.\",MSE:, The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals. The patient is suspicious and somewhat confrontative early in the session. She asked me regarding my cancellation policy, why I require seven days and not 24 hours. The patient also is irritated with paper required of her. Psychomotor is increased slightly. The patient makes strong eye contact. Speech is normal rate, rhythm, and volume. Mood is \"irritated.\" Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated. Thought is directed. Content is nondelusional. There are no auditory and no visual hallucinations. The patient has no homicidal ideation. The patient does endorse suicidal ideations. Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none. The patient states that she will not try to hurt herself currently and that she poses no risk at present. The patient notes that she does not want to go to the hospital at present. The patient is alert and oriented x 3. Recall is three for three at five minutes. Proverbs are concrete. She has fair impulse control, poor judgment, and poor insight.,FORMULATION: ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning. The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression. The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states. The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant. She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets. The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy. The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter. Symptoms are consistent with a longstanding dysthymia and reoccurring depression. In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder. This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure. This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I: Dysthymia. Major depression, moderate severity, recurrent, with partial remission.,Axis II: Borderline personality disorder.,Axis III: Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV: Medical access. Marital discord.,Axis V: A GAF of 30.,PLAN: ,The patient is unlikely to have bipolar disorder. We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic. We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure. We would also recommend dialectical behavioral therapy while the therapist is on leave. We would recommend continued treatment with SSRIs for dysthymia and depression. We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications. Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg. We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours." }

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

{ "text_length": 11496 }

{ "text": "MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx. The patient was sedated with the above medications. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal. The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air. The gastric mucosa appeared normal. The pylorus was normal. The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well. The scope was pulled back into the stomach. Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus. The scope was straightened out, the air removed and the scope withdrawn. The patient tolerated the procedure well. There were no apparent complications.," }

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

{ "text_length": 1101 }

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

{ "text_length": 1680 }

{ "text": "EXAM:, CT cervical spine (C-spine) for trauma.,FINDINGS:, CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height, alignment and interspacing are maintained. There is no evidence of fractures or destructive osseous lesions. There are no significant degenerative endplate or facet changes. No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine." }

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

{ "text_length": 531 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Obstructive sleep apnea.,POSTOPERATIVE DIAGNOSIS: ,Obstructive sleep apnea.,PROCEDURE PERFORMED:,1. Tonsillectomy.,2. Uvulopalatopharyngoplasty.,ANESTHESIA:, General endotracheal tube.,BLOOD LOSS: , Approximately 50 cc.,INDICATIONS: , The patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using CPAP, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,PROCEDURE: , After all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained. The patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the Department of Anesthesia. The patient was rotated 90 degrees away and a shoulder roll was placed and a McIvor mouthgag was inserted into the oral cavity. Correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots. Attention was directed first to the right tonsil in which a curved Allis forceps was applied to the superior pole. The needle-tip Bovie cautery was used to incise the mucosa of the anterior tonsillar pillar. Once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight Allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments. Once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,Attention was then directed over to the left tonsil in which a similar procedure was performed. Once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution. Now attention was directed to the posterior pillars. A hemostat was used to clamp the posterior pillar, which was then taken down with Metzenbaum scissors. The posterior pillar was then approximated to the anterior pillar with the use of #3-0 PDS suture so as to create a box shaped soft palate. Now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula. The mucosa was dissected off with the use of Potts scissors. Now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 PDS suture approximated with deep muscle layers. Now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 PDS sutures. Finally, #4-0 Vicryl sutures were placed intermittently between the PDS to further secure the uvula, which had been reflected onto the soft palate. A final #3-0 PDS suture was used to further approximate the anterior and posterior tonsil pillars. Final inspection did not reveal any further bleeding. The mouth was then irrigated with saline and suctioned. At this point, the procedure was complete. He was awakened and taken to recovery room in stable condition. He will be admitted as an observation patient to the Telemetry Floor for routine postoperative management. Of note, IV Decadron was administered during the procedure." }

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

{ "text_length": 3238 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:, Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE: ,The patient was taken to OR, Room #2 and administered a general anesthetic. The right upper extremity was then prepped and draped in the usual manner. A sterile tourniquet was placed on the proximal aspect of the right upper extremity. The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg. Tourniquet time was 74 minutes. A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin. Hemostasis was achieved utilizing electrocautery. Subcutaneous fat was separated and the skin flaps elevated. The _________ was identified. It was incised. The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found. There was some serosanguineous fluid from the previous rupture. This area was suctioned clean. The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface. At this point, the #2 fiber wire was then passed through the tendon. Two fiber wires were utilized in a Krackow-type suture. Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously. The radial tuberosity was palpated. Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow. A skin incision was made over this area. Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa. The tails of the fiber wire suture were grasped and pulled down through the second incision. At this point, they were placed to the side. Attention was directed at exposure of the radial tuberosity with a forearm fully pronated. The tuberosity came into view. The margins were cleared with periosteal elevator and sharp dissection. Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity. Three small drill holes were then placed along the margin for passage of the suture. The area was then copiously irrigated with gentamicin solution. A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole. The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated. The suture was tied over the bone islands. Both wounds were then copiously irrigated with gentamicin solution and suctioned dry. Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples. The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples. Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia. A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position. Tourniquet was inflated prior to application of the splint. Circulatory status returned to the extremity immediately. The patient was awakened. He was rather boisterous during his awakening, but care was taken to protect the right upper extremity. He was then transferred to the recovery room in apparent satisfactory condition." }

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

{ "text_length": 3823 }

{ "text": "HISTORY:, The patient is 14 months old, comes in with a chief complaint of difficulty breathing. Difficulty breathing began last night. He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home. They were home for about an hour when he began to get worse and they drove here to Children's Hospital. He has a history of reactive airway disease. He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time. He has been on albuterol off and on over that period. He has had fever overnight. No vomiting, no diarrhea. Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department. Normal urine output. No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above. No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:, Up-to-date.,BIRTH HISTORY:, The child was full term, no complications, home with mom. No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home. No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL: The child is awake, alert, in moderate respiratory distress.,HEENT: Pupils equal, round, reactive to light. Extraocular movements are intact. The TMs are clear. The nares show some dry secretions. Audible congestion and wheezing is noted. Mucous membranes are dry. Throat is clear. No oral lesions noted.,NECK: Supple without lymphadenopathy or masses. Trachea is midline.,LUNGS: Show inspiratory and expiratory wheezes in all fields. Audible wheezes are noted. There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART: Shows tachycardia. Regular rhythm. Normal S1, S2. No murmur.,ABDOMEN: Soft, nontender. Positive bowel sounds. No guarding. No rebound. No hepatosplenomegaly.,EXTREMITIES: Capillary refill is brisk. Good distal pulses.,NEUROLOGIC: Cranial nerves II through XII intact. Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed. I felt the child was dehydrated on examination. We gave 20 mL/kg bolus of normal saline over one hour. The child was given Solu-Medrol 2 mg/kg IV. He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally. Normal heart size. No evidence of pneumothorax. No evidence of focal pneumonia. After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. The child's pulse ox on breathing treatments with 100% oxygen was 100%. Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time. After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia. The child has a normal level of alertness; however, has not had any vomiting here. I spoke with Dr. X, on call for hospitalist service. She has come down and evaluated the patient. We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family. The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES: ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT: ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION: ,Status asthmaticus, hypoxia.,PLAN: ,Admitted to Pediatrics." }

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

{ "text_length": 4448 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct." }

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

{ "text_length": 1437 }

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

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

{ "text_length": 6830 }

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

{ "text_length": 4700 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right ureteral calculus.,POSTOPERATIVE DIAGNOSIS: , Right ureteropelvic junction calculus.,PROCEDURE PERFORMED:,1. Cystourethroscopy.,2. Right retrograde pyelogram.,3. Right double-J stent placement 22 x 4.5 mm.,FIRST SECOND ANESTHESIA: , General.,SPECIMEN:, Urine for culture and sensitivity.,DRAINS: , 22 x 4.5 mm right double-J ureteral stent.,PROCEDURE: , After consent was obtained, the patient was brought to operating room and placed in the supine position. She was given general anesthesia and then placed in the dorsal lithotomy position. A #21 French cystoscope was then passed through the urethra into the bladder. There was noted to be some tightness of the urethra on passage. On visualization of the bladder, there were no stones or any other debris within the bladder. There were no abnormalities seen. No masses, diverticuli, or other abnormal findings. Attention was then turned to the right ureteral orifice and attempts to pass to a cone tip catheter, however, the ureteral orifice was noted to be also tight and we were unable to pass the cone tip catheter. The cone tip catheter was removed and a glidewire was then passed without difficulty up into the renal pelvis. An open-end ureteral catheter was then passed ________ into the distal right ureter. Retrograde pyelogram was then performed.,There was noted to be an UPJ calculus with no noted hydronephrosis. The wire was then passed back through the ureteral catheter. The catheter was removed and a 22 x 4.5 mm double-J ureteral stent was then passed over the glidewire under fluoroscopic and cystoscopic guidance. The stent was clear within the kidney as well as within the bladder. The bladder was drained and the cystoscope was removed. The patient tolerated the procedure well. She will be discharged home. She is to follow up with Dr. X for ESWL procedure. She will be given prescription for Darvocet and will be asked to have a KUB x-ray done prior to her followup and to bring them with her to her appointment." }

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

{ "text_length": 2041 }

{ "text": "SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals. Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago. The patient had a history of hypertension and TIA/stroke. The patient denied history of heartburn and/or gastroesophageal reflux disorder. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC. The patient was seated upright in a video imaging chair throughout this assessment. To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:, Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid. Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation. Penetration was noted with cup sips of thin liquid only. Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies. The patient's hyolaryngeal elevation and anterior movement are within functional limits. Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE: ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus. Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:, No aspiration was noted during this evaluation. Penetration with cup sips of thin liquid. The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1. The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2. The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3. The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services." }

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

{ "text_length": 2843 }

{ "text": "HISTORY:, The patient is a 25-year-old gentleman who was seen in the emergency room at Children's Hospital today. He brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had \"rib cage pain\" for the last few days. He denies any history of trauma. He does have increased pain with laughing. Per the patient, he also claims to have an elevated temperature yesterday of 101. Apparently, the patient did go to the emergency room at ABCD yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to Children's.,PAST MEDICAL HISTORY: , The patient has a medical history significant for \"Staphylococcus infection\" that was being treated with antibiotics for 10 days.,CURRENT MEDICATIONS: , He states that he is currently taking no medications.,ALLERGIES: ,He is not allergic to any medication.,PAST SURGICAL HISTORY: , He denies any past surgical history.,SOCIAL HISTORY: , The patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago. He also has a history of marijuana used approximately 1 year ago. He currently states that he is in a rehab program.,FAMILY HISTORY:, Unknown by the patient.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,GENERAL: He is alert and appeared to be in no acute distress. He had normal hydration.,HEENT: His pupils were equal, round, reactive. Extraocular muscles intact. He had no erythema or exudate noted in his posterior oropharynx.,NECK: Supple with full range of motion. No lymphadenopathy noted.,RESPIRATORY: He had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,CARDIOVASCULAR: Regular rate and rhythm. Positive S1, S2. No murmurs, rubs, or gallops noted.,GI: Nontender, nondistended with normoactive bowel sounds. No masses noted.,SKIN: Appeared normal except on the left anterior tibial area where the patient had a healing skin lesion. There were no vesicles, erythema or induration noted.,MUSCULOSKELETAL: Nontender with normal range of motion.,NEURO/PSYCHE: The patient was alert and oriented x3 with nonfocal neurological exam.,ASSESSMENT: , This is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,PLAN: , Due to the fact that this patient is an adult male, we will transfer him to XYZ Medical Center for further evaluation. I have spoken with XYZ Medical Center Dr. X who has accepted the patient for transfer. He was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress. Dr. X was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork. The plan was explained in detail to the patient who stated that he understood and would comply. The appropriate paperwork was created and one copy was given to the patient.,CONDITION ON DISCHARGE: , At the time of discharge, he was stable, vital signs stable, in no acute distress." }

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

{ "text_length": 3277 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant. The patient did well after the liver transplant and the only problems started:,1. History of food allergies.,2. History of dental cavities.,At this time, the patient came for a followup and is complaining of a left upper molar pain. There are no other complaints.,DIET: , Lactose-limited diet.,MEDICATIONS: , Please see the MRC form.,ALLERGIES: , There are no allergies.,SOCIAL HISTORY:, The patient lives with the parents in Lindsay, California and has a good environment.,FAMILY HISTORY: , Negative for gastrointestinal illness except that a sibling has ulcerative colitis.,REVIEW OF SYSTEMS: , The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,PHYSICAL EXAMINATION: ,MEASUREMENTS: Height 135 cm and weight 28.1 kg.,VITAL SIGNS: Temperature 98.9 and blood pressure 105/57.,GENERAL: A well-developed, well-nourished child in no acute distress.,HEENT: Atraumatic and normocephalic. The pupils are equal, round, and reactive to light. Full EOMs. The conjunctivae and sclerae are clear. The TMs show normal landmarks. The nasal mucosa is pink and moist. The teeth and gums are in good condition. The pharynx is clear.,NECK: Supple, without thyromegaly and without masses.,LYMPHATIC: No adenopathy.,LUNGS: Clear to auscultation, with no retractions.,CORONARY: Regular rhythm without murmur. S1 and S2 are normal. The pulses are full and symmetrical bilaterally.,ABDOMEN: Normal bowel sounds. No hepatosplenomegaly, no masses, and no tenderness.,GENITALIA: Normal female by inspection.,SKIN: No unusual lesions.,BACK: No scoliosis, hairy patch, lipoma, or sacral dimple.,EXTREMITIES: No cyanosis, clubbing, or edema.,CENTRAL NERVOUS SYSTEM: Developmentally appropriate for age. DTRs are 2+ and symmetrical. The toes are downgoing bilaterally. Motor and sensory without asymmetry. Cranial nerves II through XII are grossly intact.,LABORATORY DATA:, Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected.,FINAL IMPRESSION:, This is a 10-year-old with history of:,1. Biliary atresia.,2. Status post orthotopic liver transplantation.,3. Dental cavities.,4. Food allergies.,5. History of urinary tract infections.,PLAN: , Our plan would be to continue with the medications as follows:,1. Prograf 0.5 mg p.o. b.i.d.,2. Valganciclovir 420 mg p.o. b.i.d.,3. Labs every 2 to 3 months.,4. To return to clinic in 4 months.,5. To refer this patient to a pediatric dentist for assessment of the dental cavities." }

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

{ "text_length": 2734 }

{ "text": "PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition." }

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

{ "text_length": 1641 }

{ "text": "PROCEDURE PERFORMED:, Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing. The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein. Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein. A steel guidewire was then inserted through the needle into the vessel without resistance. Small nick was then made in the skin and the needle was removed. An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance. The guidewire and dilator were then removed. The sheath was then flushed. A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated. Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position. Hemodynamics were measured along the way. Pulmonary artery saturation was obtained. The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration. The patient tolerated the procedure well. The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:, Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula. Pulmonary artery saturation equals 37.8. Pulse oximetry on 2 liters nasal cannula equals 93%. Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION: ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor. The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia. At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy. We will also increase his Lasix to 80 mg IV q.d. We will increase his amiodarone to 400 mg daily. We will also continue with his Coumadin therapy. As stated previously, we will discontinue vasodilator therapy starting with the Isordil." }

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

{ "text_length": 3117 }

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

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

{ "text_length": 1838 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED: ,Total hip arthroplasty on the left.,ANESTHESIA: ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS: ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis. This was revealed once we removed the trochanteric bursa.,HISTORY: ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis. She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure. All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure. The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03. The general anesthetic was first performed by the Department of Anesthesia. The patient was then positioned with the left hip exposed on the beanbag in the lateral position. Kidney rests were also used because of the patient's size. An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse. All her bony prominences were well padded. At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure. At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat. The tensor fascia lata was then identified. A self-retainer was then inserted to expose the operative field. Bovie cautery was used for hemostasis. At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter. At this time, a blunt dissection was taken proximally. The tensor fascia lata was occluded with a hip retractor. At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius. At this time, a periosteal elevator was used to expose anterior hip capsule. A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle. Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck. At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum. At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum. At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum. At this time, a femoral stem guide was then used to measure proximal femoral neck cut. We made a cut approximately a fingerbreadth above the lesser trochanter. At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed. At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum. A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum. With better exposure of the acetabulum, we started reaming the acetabulum. We started with a size #44 and progressively reamed to a size #50. At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum. We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum. A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in. Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum. At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup. At this time, a plastic liner was then inserted for protection. The leg was then placed back in the bag. A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur. A rongeur was used to lateralize over the greater trochanter. A Box osteotome was used to remove the cancellous portion of the femoral neck. A Charnley awl was then used to cannulate through the proximal femoral canal. A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem. At this time, we began broaching. We started with a size #10 and progressively worked up to a size #12 mm broach. Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar. A calcar reamer was then placed and the calcar was reamed smoothly. A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed. Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation. At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum. This was impacted and placed and checked to assure that it was well seated with no loosening. Once this was performed, we then exposed the proximal femur one more time. We copiously irrigated within the canal and then suctioned it dry. At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place. Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none. The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion. We were satisfied with components as well as the alignment of the components. Copious irrigation was then used to irrigate the wound. #1 Ethibond was then used to approximate the anterior hip capsule. #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter. Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure. A tight closure was performed. Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin. Staples were then used for skin closure. The patient's hip was then cleansed. Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed. A drain was placed prior to wound closure for postoperative drainage. After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition. Prognosis is good." }

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

{ "text_length": 8646 }

{ "text": "INFORMANT:, Dad on phone. Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY: ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease. The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis. All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done. The patient was put on ampicillin and cefotaxime. Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime. The patient was n.p.o. when he came in. He was on 3/4 L of oxygen. According to the note, it conveyed that he had some subcostal retractions. On arriving here, baby looks very healthy. He has no subcostal retractions. He is not requiring any oxygen and he is positive for urine and stool. The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile. ED called that case is a direct admit.,REVIEW OF SYSTEMS: ,The patient supposedly had fever, some weight loss, poor appetite. The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria. According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color. He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low. Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:, None.,HOSPITALIZATIONS:, Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY: ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications. Hospital stay 24 hours. Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:, None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY: ,Lives with mom and dad. Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog. They usually visit to a ranch, but not recently. No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:, No allergies.,DIET:, Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS: Weight 3.725 kg.,GENERAL: Alert and comfortable and sleeping.,SKIN: No rash.,HEENT: Intact extraocular movements. PERRLA. No nasal discharge. No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK: Soft, nontender, supple.,CHEST: CTAP.,GI: Bowel sounds present. Nontender, nondistended.,GU: Bilaterally descended testes.,BACK: Straight.,NEUROLOGIC: Nonfocal.,EXTREMITIES: No edema. Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:, As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000. Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5. Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4. Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal. UA and LP results are pending. Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative. We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime. The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis. These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient. He does not need any further workup.,GASTROINTESTINAL: " }

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

{ "text_length": 4596 }

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

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

{ "text_length": 2126 }

{ "text": "The right eardrum is intact showing a successful tympanoplasty. I cleaned a little wax from the external meatus. The right eardrum might be very slightly red but not obviously infected. The left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue. Also some wax at the external meatus I cleaned with a Q-tip with peroxide. The patient has no medical allergies. Since he recently had a course of Omnicef we chose to put him on Augmentin (I checked and we did not have samples), so I phoned in a two-week course of Augmentin 400 mg chewable twice daily with food at Walgreens. I looked at this throat which looks clear. The nose only has a little clear mucinous secretions. If there is any ear drainage, please use the Floxin drops. I asked Mom to have the family doctor (or Dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection. I plan to see the patient again later this spring." }

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

{ "text_length": 1012 }

{ "text": "GENERAL: Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC: Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT: Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC: Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY: Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL: Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY: Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY: Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC: Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC: Negative for any abnormal bruising, frequent infections or bleeding." }

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

{ "text_length": 975 }

{ "text": "REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:, The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life. The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds. At that time, her daughter was with her. No tonic-clonic movements. No cyanosis. The patient woke up on her own. The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years. She cannot get up one flight of stairs, but feels short of breath. She gets exerted and thinks to take a shower. She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1. Pulmonary embolism diagnosed one year ago. At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers. Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2. Coronary artery disease status post CABG at that time. She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3. Mitral regurgitation.,4. Gastroesophageal reflux disease.,5. Hypertension.,6. Hyperlipidemia.,7. History of aortic aneurysm.,8. History of renal artery stenosis.,9. Peripheral vascular disease.,10. Hypothyroidism.,PAST SURGICAL HISTORY,1. CABG.,2. Hysterectomy.,3. IVC filter.,4. Tonsillectomy.,5. Adenoidectomy.,6. Cosmetic surgery.,7. Renal stent.,8. Right femoral stent.,HOME MEDICATIONS,1. Aspirin.,2. Potassium.,3. Lasix.,4. Levothyroxine.,5. Lisinopril.,6. Pacerone.,7. Protonix.,8. Toprol.,9. Vitamin B.,10. Zetia.,11. Zyrtec.,ALLERGIES:, SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore. She drinks 2 to 3 glasses of wine per week. She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE: In no acute distress.,VITAL SIGNS: Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT: No lymph nodes or masses.,NECK: No jugular venous distension.,LUNGS: Clear to auscultation bilaterally." }

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

{ "text_length": 2382 }

{ "text": "DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:, 0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well. He is working. He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics. Overall when he compares his strength to six or eight months ago he notes that he feels much stronger. He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs: Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT: Extraocular muscles intact. Sclerae not icteric. Oral cavity free of exudate or ulceration. Dry mouth noted.,Lymph: No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs: Clear.,Cardiac: Rhythm regular.,Abdomen: Soft, nondistended. Neither liver, spleen, nor other masses palpable.,Lower Extremities: Without edema.,Neurologic: Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1. This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal. I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy. He has made a good recovery. We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up. We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC." }

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

{ "text_length": 2083 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter." }

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

{ "text_length": 839 }

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

{ "text_length": 4004 }

{ "text": "DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1. Glucosamine complex.,2. Toprol XL.,3. Alprazolam,4. Hydrochlorothiazide.,5. Dyazide.,6. Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck. She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area. As such, I feel that we could safely re-treat the lower neck. Her weight has increased to 189.5 from 185.2. She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK: On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area. No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY: Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected. No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN: Normal bowel sounds, no hepatomegaly. No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress. Thank you for having allowed me to participate in her care." }

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

{ "text_length": 1668 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago. The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction. Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed. The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space. The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space. During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved. The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed. The ureter was encountered during the course of resection, but was not ligated. The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS: 900 mL." }

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

{ "text_length": 1742 }

{ "text": "Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero." }

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

{ "text_length": 10434 }

{ "text": "ADMISSION DIAGNOSES:,1. Menometrorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,DISCHARGE DIAGNOSES:,1. Menorrhagia.,2. Dysmenorrhea.,3. Small uterine fibroids.,OPERATION PERFORMED: ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL: ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries. She is having increasing menometrorrhagia and dysmenorrhea. Ultrasound shows a small uterine fibroid. She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY: ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES: ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia. Postoperatively, she has done well. Bowel and bladder function have returned normally. She is ambulating well, tolerating a regular diet. Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good." }

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

{ "text_length": 1200 }

{ "text": "TITLE OF OPERATION:, Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:, 900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid. No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:, After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered. She was examined under anesthesia. An 8-10 cm anteverted uterus was noted. The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy. Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus. The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity. Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water. No peritoneum was obtained without difficulty using 4 liters of CO2 gas. The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized. A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point. Under direct visualization, the trocar and sleeve were advanced without difficulty. A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep. The peritoneal fluid was aspirated and sent for culture and wash and cytology. The abdomen and pelvis were surveyed with the above-noted findings. No active bleeding was noted. No evidence of ectopic pregnancy was noted. The instruments were removed from the abdomen under good visualization with good hemostasis noted. The sponge on a sponge stick was removed from the vagina. The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure." }

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

{ "text_length": 2797 }

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

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

{ "text_length": 5885 }

{ "text": "GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation." }

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

{ "text_length": 2327 }

{ "text": "DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP: ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:, Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition." }

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

{ "text_length": 2823 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION: ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition." }

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

{ "text_length": 4054 }

{ "text": "HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery. Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1. The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration. At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present. The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2. The patient will increase accuracy of yes-no responses to greater than 80% accuracy. She did accomplish this goal. The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established. Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently. The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions. The patient continues to have marked difficulty with her expressive language abilities. She is able to write simple words to help express her basic wants and needs. She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions. A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4. Once again, she made significant improvement and comprehension, but continues to have unintelligible speech. An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device. If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her. Please reconsult at that time if and when the patient is ready to use a speech generating device. The patient is discharged from my services at this time due to a plateau in her progress. Numerous home activities were recommended to allow her to continue to make progress at home." }

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

{ "text_length": 3037 }

{ "text": "HISTORY OF PRESENT ILLNESS:, This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension. Patient has severe backache secondary to disc herniation. Patient has seen an orthopedic doctor and is scheduled for surgery. Patient also came to my office for surgical clearance. Patient had cardiac cath approximately four years ago, which was essentially normal. Patient is documented to have morbid obesity and obstructive sleep apnea syndrome. Patient does not use a CPAP mask. Her exercise tolerance is eight to ten feet for shortness of breath. Patient also has two-pillow orthopnea. She has intermittent pedal edema.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure is 135/70. Respirations 18 per minute. Heart rate 70 beats per minute. Weight 258 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Clear. ,CARDIOVASCULAR: There is no murmur or gallop heard over the precordium. ,ABDOMEN: Soft. There is no hepatosplenomegaly. ,EXTREMITIES: The patient has no pedal edema. ,MEDICATIONS: ,1. BuSpar 50 mg daily.,2. Diovan 320/12.5 daily.,3. Lotrel 10/20 daily.,4. Zetia 10 mg daily.,5. Ambien 10 mg at bedtime.,6. Fosamax 70 mg weekly.,DIAGNOSES:,1. Controlled hypertension.,2. Morbid obesity.,3. Osteoarthritis.,4. Obstructive sleep apnea syndrome.,5. Normal coronary arteriogram.,6. Severe backache.,PLAN:,1. Echocardiogram, stress test.,2 Routine blood tests.,3. Sleep apnea study.,4. Patient will be seen again in my office in two weeks." }

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

{ "text_length": 1657 }

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

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

{ "text_length": 1370 }

{ "text": "ADMITTING DIAGNOSES:, Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:, Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1. Chronic obstructive pulmonary disease.,2. Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts. He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma. Of note, there are no other enhancing solid masses seen on this MRI. After discussion of multiple management strategies with the patient including:,1. Left partial nephrectomy.,2. Left radical nephrectomy.,3. Left renal cyst decortication. The patient is likely to undergo the latter procedure.,HOSPITAL COURSE: ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy. Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed. The contents were aspirated and careful dissection of the cyst wall was performed. Multiple specimens of the cyst wall were sent for pathology. Approximately one liter of cystic fluid was drained during the procedure. The renal bed was inspected for hemostasis, which appear to be adequate. There were no complications with the procedure. Single JP drain was left in place. Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra. Furthermore, no gross lesions were encountered in the bladder. The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful. His diet and activity were gradually advanced without complication. On postoperative day #2, he was passing flatus and has had bowel movements. His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge. His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly. At the time of discharge, he was afebrile. His vital signs indicated hemodynamic stability and he had no evidence of infection. The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:, Good.,MEDICATIONS: ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment." }

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

{ "text_length": 2975 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right buccal and canine's base infection from necrotic teeth. ICD9 CODE: 528.3.,POSTOPERATIVE DIAGNOSIS: , Right buccal and canine's base infection from necrotic teeth. ICD9 Code: 528.3.,PROCEDURE: , Incision and drainage of multiple facial spaces; CPT Code: 40801. Surgical removal of the following teeth. The teeth numbers 1, 2, 3, 4, and 5. CPT code: 41899 and dental code 7210.,SPECIMENS: , Cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,DRAINS: ,A 1.5 inch Penrose drain placed in the right buccal and canine space.,ESTIMATED BLOOD LOSS:, 40 Ml.,FLUID: ,700 mL of crystalloid.,COMPLICATIONS: ,None.,CONDITION: ,The patient was extubated breathing spontaneously to the PACU in good condition.,INDICATION FOR PROCEDURE: ,The patient is a 41-year-old that has a recent history of toothache and tooth pain. She saw her dentist in Sacaton before Thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. The patient neglected to return to the dentist until this weekend for IV antibiotics and definitive treatment. She noticed on Friday that her face was starting to swell up a little bit and it progressively got worse. The patient was admitted to the hospital on Monday for IV antibiotics. Oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. The patient was worked up preoperatively by anesthesia and Oromaxillary Facial Surgery. It was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room and laid on the operating room table on supine fashion. ASA monitors were attached as stated. General anesthesia was induced with IV anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. The patient was prepped and draped in usual oromaxillary facial surgery fashion.,An 18-gauze needle of 20 mL syringe was used to aspirate the pus out of the right buccal space. This pus was then cultured and sent to micro lab for cultures and sensitivities. Approximately 7 mL of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. After waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. Mouth rinse was then poured into the oral cavity. The mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. Using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,A full thickness mucoperiosteal flap was developed and approximately 6 mL of pus was instantly drained from the buccal space. It was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. Tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. It was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. Using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. The extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. Dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. This site was then irrigated with copious amounts of sterile water. There was still noted to be induration in the buccal mucosa so #15 blade was used anterior to Stensen duct. A 2 cm incision was made and using a Hemostat blunt dissection in to the buccal mucosa was performed. A little-to-no pus was received. Using a half-inch Penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 Ethilon suture. Remainder of the flap was left open to drain. Further examination of the floor of mouth was soft. The lateral pharynx was nonindurated or swollen. At this point, the throat pack was removed and OG tube was placed and the stomach contents were evacuated. The procedure was then determined to be over. The patient was extubated, breathing spontaneously, and transferred to the PACU in excellent condition." }

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

{ "text_length": 4627 }

{ "text": "INDICATIONS:, Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142. ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:, The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:, It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds. There is normal LV myocardial perfusion. The LV systolic ejection fraction is normal at 65%. There is normal global and regional wall motion.,CONCLUSIONS:,1. Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2. Normal LV myocardial perfusion.,3. Normal LV systolic ejection fraction of 65%.,4. Normal global and regional wall motion." }

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

{ "text_length": 851 }

{ "text": "EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 69-year-old male with pain in the shoulder. Evaluate for rotator cuff tear.,FINDINGS:,Examination was performed on 9/1/05.,There is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. There is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. There is no retracted tendon or muscular atrophy (series #6 images #6-17).,Normal infraspinatus tendon.,There is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). There is no complete tear, gap or fiber retraction and there is no muscular atrophy.,There is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. The biceps anchor is intact. There are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,There is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). There is a small sublabral foramen at the eleven o’clock position (series #9 image #6). There is no osseous Bankart lesion.,Normal superior, middle and inferior glenohumeral ligaments.,There is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion (series #8 images #3-12).,Normal coracoacromial, coracohumeral and coracoclavicular ligaments. There is minimal fluid within the glenohumeral joint. There is no atrophy of the deltoid muscle.,IMPRESSION:, There is extensive supraspinatus tendinosis and partial tearing as described. There is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. There is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. There is no evidence of a complete tear or retracted tendon. Small nondisplaced posterior superior labral tear. Outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an MRI manifestation of an impinging lesion." }

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

{ "text_length": 2794 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft. Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table. After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner. Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw. Pericardial and thymus fat pad was divided. The left internal mammary artery was harvested and spatulated for anastomosis. Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips. The thigh was closed multilayer Vicryl and Dexon technique. A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors. After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia. Medtronic retractors used to expose the circumflex. Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique. The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique. Deairing procedure was carried out. The bulldogs were removed. The patient maintained good normal sinus rhythm with good mean perfusion. The patient was weaned from cardiopulmonary bypass. The arterial and venous lines were removed and doubly secured. Protamine was delivered. Meticulous hemostasis was present. Platelets were given for coagulopathy. Chest tube was placed and meticulous hemostasis was present. The anatomy and the flow in the grafts was excellent. Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique. The skin was closed with subcuticular 4-0 Dexon suture technique. The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0." }

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

{ "text_length": 3034 }

{ "text": "SUBJECTIVE:, This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.,CURRENT MEDICATIONS:, Advair and Allegra. He has been taking these regularly. He is not sure the Allegra is working for him anymore. He does think though better than Claritin.,PHYSICAL EXAM:,General: Alert young man in no distress.,HEENT: TMs clear and mobile. Pharynx clear. Mouth moist. Nasal mucosa pale with clear discharge.,Neck: Supple without adenopathy.,Heart: Regular rate and rhythm without murmur.,Lungs: Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen: Soft, nontender, without masses or splenomegaly.,ASSESSMENT:, I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:, Change to Zyrtec 10 mg samples were given. He is not using nasal spray, but he has some at home. He should restart this. Continue to watch his peak flows to make sure his asthma does not come under poor control. Call if any further problems." }

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

{ "text_length": 1185 }

{ "text": "PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments. The GIF-160 diagnostic gastroscope used. The patient was alert during the procedure. The esophagus was intubated under direct visualization. The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted. The stomach was unremarkable. Retroflexed exam unremarkable. Duodenum not intubated in order to minimize the time spent during the procedure. The patient was alert although not combative. A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds. The balloon was then deflated. The patient became uncomfortable and a good-size adequate distal esophageal tear was noted. The scope and balloon were then withdrawn. The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed. This has been discussed with the parents. He was sent home with a prescription for omeprazole." }

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

{ "text_length": 1549 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Normal colon with no evidence of bleeding.,2. Hiatal hernia.,3. Fundal gastritis with polyps.,4. Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN: ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes. She has been anemic as well with no gross evidence of blood loss. She has had a decreased appetite with weight loss greater than 20 lb over the past few months. After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After 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 was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids. The colonoscope was inserted into the rectum and air was insufflated. The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum. There were no polyps, masses, diverticuli, or areas of inflammation. The scope was then slowly withdrawn carefully examining all walls. Air was aspirated. Once in the rectum, the scope was retroflexed. There was no evidence of perianal disease. No source of the anemia was identified.,Attention was then taken for performing an EGD. The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx. The esophagus was easily intubated and traversed. There were no abnormalities of the esophagus. The stomach was entered and was insufflated. The scope was coursed along the greater curvature towards the antrum. Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______. It was not clear if this represents a healing ulcer or neoplasm. Several biopsies were taken. The mass was soft. The pylorus was then entered. The duodenal bulb and sweep were examined. There was no evidence of mass, ulceration, or bleeding. The scope was then brought back into the antrum and was retroflexed. In the fundus and body, there was evidence of streaking and inflammation. There were also several small sessile polyps, which were removed with biopsy forceps. Biopsy was also taken for CLO. A hiatal hernia was present as well. Air was aspirated. The scope was slowly withdrawn. The GE junction was unremarkable. The scope was fully withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes. We will await the biopsy reports and further recommendations will follow." }

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

{ "text_length": 2938 }

{ "text": "EXAM:,MRI-UP EXT JOINT LEFT SHOULDER,CLINICAL:,Left shoulder pain. Evaluate for rotator cuff tear.,FINDINGS:, Multiple T1 and gradient echo axial images were obtained, as well as T1 and fat suppressed T2-weighted coronal images.,The rotator cuff appears intact and unremarkable. There is no significant effusion seen. Osseous structures are unremarkable. There is no significant downward spurring at the acromioclavicular joint. The glenoid labrum is intact and unremarkable.,IMPRESSION:, Unremarkable MRI of the left shoulder.," }

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

{ "text_length": 530 }

{ "text": "EXAM:, Skull, complete, five images,HISTORY:, Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated. There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure. There is no evidence of any craniosynostosis. There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly." }

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

{ "text_length": 505 }

{ "text": "REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted. She has no other significant findings other than her overactive bladder, which had continued. At this juncture what I would like to do is try a different anticholinergic medication. She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan. We will start Sanctura XR and we will follow up as scheduled. Otherwise we will continue to follow her urinalysis over the next year or so." }

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

{ "text_length": 1211 }

{ "text": "REASON FOR CONSULT:, Renal insufficiency.,HISTORY OF PRESENT ILLNESS:, A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.,REVIEW OF SYSTEMS:, Reviewed entirely and negative except for HPI.,PAST MEDICAL HISTORY:, Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY:, The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.,GENERAL: A 48-year-old African-American male in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.,NECK: No JVD, bruit, or lymphadenopathy.,HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.,LUNGS: Clear. No wheezes or crackles.,ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.,EXTREMITIES: No cyanosis, clubbing, or edema.,CNS: Exam is nonfocal.,LABS:, WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.,ASSESSMENT:, A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:,1. Hypertensive emergency.,2. Acute on chronic renal failure.,3. Urine drug screen positive.,4. Question CHF versus COPD exacerbation.,PLAN:,1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.,2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.,Thank you for this consult. We will continue to follow the patient with you." }

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

{ "text_length": 2564 }

{ "text": "CHIEF COMPLAINT:, Jaw pain this morning.,BRIEF HISTORY OF PRESENT ILLNESS:, This is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out MI and coronary artery disease. The patient has history of hypercholesterolemia, presently on Lipitor 20 mg a day and hyperthyroidism, on Synthroid 0.088 mg per day. Also, history of chronic diverticulitis with recent bouts. The patient has been doing well, seen in my office at the end of December for complete physical examination. I had ordered a stress test for him, then delayed due to a family illness. However, denies any chest pain or chest tightness with exertion. The patient was doing well. He was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. He awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. He is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. The patient's pain resolved. He was given nitroglycerin in the emergency room drawing his blood pressure 67/32. Blood pressure quickly came back to normal with the patient's reverse Trendelenburg.,FAMILY HISTORY: , Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink.,PAST MEDICAL HISTORY:, Remarkable for tonsillectomies.,MEDICATIONS:, Synthroid and Lipitor.,ALLERGIES:, PENICILLIN AND BIAXIN.,REVIEW OF SYSTEMS:, Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. He is afebrile.,GENERAL: He is well-developed, well-nourished white male, in no acute distress.,HEENT: Pupils equal, round, and reactive to light and accommodation. Extraocular movements were intact. Throat was clear.,NECK: Supple. There is no organomegaly or thyromegaly. Carotids are +2 without bruits.,CHEST: Lungs are clear to auscultation and percussion.,CV: Without any murmurs or gallops.,ABDOMEN: Soft. There is no hepatosplenomegaly. Bowel sounds are active. No tenderness.,EXTREMITIES: No cyanosis, clubbing, or edema. Peripheral pulses 2+.,NEUROLOGICAL: Intact. Motor exam is 5/5.,LABORATORY STUDIES:, EKG is within normal limits, good sinus rhythm. His axis is somewhat leftward. CBC and BMP were normal and cardiac enzymes were negative x1.,IMPRESSION:,1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent.,2. Hypercholesterolemia.,3. Hypothyroidism.,PLAN: , Lipitor and thyroid have been ordered. His chest pain unit protocol for the stress thallium that will be done in the morning. If test is negative, we will discharge home. If positive, we will consult Cardiology. The patient requests Dr. ABC." }

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

{ "text_length": 3124 }

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

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

{ "text_length": 1522 }

{ "text": "Sample Address,RE: Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today. As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. He has been having problems with wheezing, cough and shortness of breath over the last several months. You and your partners have treated him aggressively with inhaled steroids and bronchodilator. Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course. ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister. The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house. ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy. ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this. I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization. ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days). I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care. ,Sincerely," }

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

{ "text_length": 1795 }

{ "text": "CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. She was admitted to the hospital. The MRI showed only an old right basal ganglion infarct. She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP. The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. Her vital capacities were normal during the hospitalization. Her chest x-ray was negative for any acute process. She was discharged to rehab from July 12, 2006 to July 20, 2006. She made some progress in which she notes that her walking is definitely better. However, she notes that she still has some problems with eye movement and her vision. This is possibly her main problem. She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:, Documented in the clinic note. The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1. Hypertension.,2. Diabetes mellitus.,3. Stroke involving the right basal ganglion.,4. Guillain-Barre syndrome diagnosed in June of 2006.,5. Bilateral knee replacements.,6. Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:, Multiple family members have diabetes mellitus.,SOCIAL HISTORY:, The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.,MEDICATIONS:, Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. Pain scale 5/10. Please see the written note for details. General exam is benign other than mild obesity. On neuro examination, mental status is normal. Cranial nerves are significant for full visual fields and pupils are equal and reactive. However, extraocular movements are very limited. She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. Face is symmetric. Sensation is intact. Tongue and uvula are in midline. Palate is elevated symmetrically. Shoulder shrug is strong. The patient's muscle exam shows normal bulk and tone throughout. She has no weakness of the left upper extremity. In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. There is no drift or orbit. Reflexes are absent throughout. Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. There is no dysmetria. Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:, As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. The patient has shown some improvement with IVIG and continues to show some gradual improvement. I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. She is scheduled to see an ophthalmologist. I think it is reasonable for close followup of her visual symptoms progress. However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further. I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week. She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable. I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1. Guillain-Barre Miller-Fisher variant.,2. Hypertension.,3. Diabetes mellitus.,4. Stroke.,RECOMMENDATIONS:,1. The patient is to start taking aspirin 162 mg per day.,2. Followup with ophthalmology.,3. Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4. Followup by phone in three to four weeks.,5. Followup in this clinic in approximately two months' time.,6. Call for any questions or problems." }

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

{ "text_length": 5201 }

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

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

{ "text_length": 3153 }

{ "text": "PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain. We decided go ahead with anterior cervical discectomy at C5-C6 and fusion. The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication. The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut. He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded. The tape was placed and his arms were well padded. He was prepped and draped in a sterile fashion. A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle. We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle. We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region. We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space. We then marked the disc space. We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space. We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates. We took down posterior longitudinal ligament as well. We incised the 6-mm cornerstone bone. We placed a 6-mm parallel medium bone nicely into the disc space. We then sized a 23-mm plate. We inserted the screws nicely above and below. We tightened down the lock-nuts. We irrigated the wound. We assured hemostasis using bone wax prior to placing the plate. We then assured hemostasis once again. We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion. The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion. The skin was closed with 3-0 Monocryl in a running subcuticular stitch. Steri-Strips were applied. Dry sterile dressing with Telfa was applied over this. We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs. I was present as a primary surgeon throughout the entire case." }

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

{ "text_length": 2871 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:, Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1. Tympanostomy and tube placement.,2. Adenoidectomy.,ANESTHESIA: ,General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was taken to the operating room, prepped and draped in the usual fashion. After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied. Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx. With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior. The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made. Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle. Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition." }

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

{ "text_length": 1979 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA: ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection. He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer. Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the table was then turned. A shoulder roll placed under the shoulders and the face was placed in an extended fashion. The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion. A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode. Subplatysmal superior and inferior flaps were raised. The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4. The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck. This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region. The submandibular gland was removed as well. The X, XI, and XII cranial nerves were preserved. The internal jugular vein and carotid artery were preserved as well. Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure. There were two obviously positive nodes in this neck dissection. One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2. A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature. The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples. A fluff and Kling pressure dressing was then applied. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications." }

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

{ "text_length": 2892 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1. Maxillary atrophy.,2. Severe mandibular atrophy.,3. Acquired facial deformity.,4. Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m. Nasal trachea intubation was performed per routine. The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report. Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft. Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft. Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine. Surgical team scrubbed and gowned in usual fashion and the patient was draped. Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa. A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion. Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region. The contents of the neurovascular canal from the greater palatine foramina were identified. The hard palate was directly observed. The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine. Similar features were reflected on the contralateral side. The area was re-contoured with rongeurs. The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable. A surgical mallet then compressed this bone further into the region. A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla. Particulate bone was then placed around the remaining block of bone. A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block. The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex. Attention was brought then to the mandible. 1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given. A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body. The anterior body was found to be approximately 3 mm in height. A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved. A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible. A similar procedure was done on the contralateral side. The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair. A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws. The block of bone was further re-contoured in situ. Particulate bone was then injected into the posterior tunnels bilaterally. A piece of AlloDerm was placed over those particulate segments. The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form. The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc. The estimated blood loss in the intraoral procedure was 220 cc. Total blood loss for the procedure 320 cc. The fluid administered 300 cc. The urine out 180. All sponges were counted encountered for as were sutures. The patient was taken to Recovery at approximately 12 o'clock noon." }

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

{ "text_length": 4861 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,POSTOPERATIVE DIAGNOSIS:, Benign prostatic hyperplasia.,OPERATION PERFORMED: , Transurethral electrosurgical resection of the prostate.,ANESTHESIA: , General.,COMPLICATIONS:, None.,INDICATIONS FOR THE SURGERY:, This is a 77-year-old man with severe benign prostatic hyperplasia. He has had problem with urinary retention and bladder stones in the past. He will need to have transurethral resection of prostate to alleviate the above-mentioned problems. Potential complications include, but are not limited to:,1. Infection.,2. Bleeding.,3. Incontinence.,4. Impotence.,5. Formation of urethral strictures.,PROCEDURE IN DETAIL: , The patient was identified, after which he was taken into the operating room. General LMA anesthesia was then administered. The patient was given prophylactic antibiotic in the preoperative holding area. The patient was then positioned, prepped and draped. Cystoscopy was then performed by using a #26-French continuous flow resectoscopic sheath and a visual obturator. The prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe. The anterior urethra was normal without strictures or lesions. The bladder was severely trabeculated with multiple bladder diverticula. There is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone. Using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe. Once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down. Once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an Ellik evacuator. A 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis. The sheath was then removed under direct vision and a #24-French Foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained. The patient tolerated the operation well." }

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

{ "text_length": 2104 }

{ "text": "CHIEF COMPLAINT:, Abdominal pain and discomfort for 3 weeks.,HISTORY OF PRESENT ILLNESS:, ,The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.,The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.,There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable.,PAST MEDICAL HISTORY :, None. No history of hypertension, diabetes, heart disease, liver disease or cancer.,PAST SURGICAL HISTORY:, Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.,GYN HISTORY:, Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.,FAMILY HISTORY:, Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father’s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome.,SOCIAL HISTORY:, No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.,MEDICATION:, None.,REVIEW OF SYSTEMS:, No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air,GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions.,NECK: Supple, no masses, jugular venous distention or bruits.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs, gallops, rubs.,BREASTS: Symmetric, no skin changes, no discharge, no masses,ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly.,PELVIC: not done,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions; no tattoos,STUDIES:,CT Chest: Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.,MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.,Total Body Bone Scan: No abnormal uptake.,HOSPITAL COURSE:, ,The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done." }

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

{ "text_length": 4799 }

{ "text": "CHIEF COMPLAINT:, Rule out obstructive sleep apnea syndrome.,Sample Patient is a pleasant, 61-year-old, obese, African-American male with a past medical history significant for hypertension, who presents to the Outpatient Clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. He denies any gasping, choking, or coughing episodes while asleep at night. His bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. He has two to three episodes of nocturia per night. He denies any morning symptoms. He has mild excess daytime sleepiness manifested by dozing off during boring activities.,PAST MEDICAL HISTORY:, Hypertension, gastritis, and low back pain.,PAST SURGICAL HISTORY:, TURP.,MEDICATIONS:, Hytrin, Motrin, Lotensin, and Zantac.,ALLERGIES:, None.,FAMILY HISTORY:, Hypertension.,SOCIAL HISTORY:, Significant for about a 20-pack-year tobacco use, quit in 1991. No ethanol use or illicit drug use. He is married. He has one dog at home. He used to be employed at Budd Automotors as a die setter for about 37 to 40 years.,REVIEW OF SYSTEMS:, His weight has been steady over the years. Neck collar size is 17½\". He denies any chest pain, cough, or shortness of breath. Last chest x-ray within the past year, per his report, was normal.,PHYSICAL EXAM:, A pleasant, obese, African-American male in no apparent respiratory distress. T: 98. P: 90. RR: 20. BP: 156/90. O2 saturation: 97% on room air. Ht: 5' 5\". Wt: 198 lb. HEENT: A short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no JVD. CARDIAC: Regular rate and rhythm without any adventitious sounds. CHEST: Clear lungs bilaterally. ABDOMEN: An obese abdomen with active bowel sounds. EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Non-focal.,IMPRESSION:,1. Probable obstructive sleep apnea syndrome.,2. Hypertension.,3. Obesity.,4. History of tobacco use.,PLAN:,1. We will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2. Encouraged weight loss.,3. Check TSH.,4. Asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5. Asked to return to the clinic one week after sleep the study is done." }

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

{ "text_length": 2378 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS: ,Fracture dislocation, C2.,OPERATION PERFORMED,1. Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2. Posterior spinal instrumentation C1-C3, using Synthes system.,3. Posterior cervical fusion C1-C3.,4. Insertion of morselized allograft at C1to C3.,ANESTHESIA:, GETA.,ESTIMATED BLOOD LOSS:, 100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:, Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:, The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture. This is secondary to a motor vehicle accident and it was translated appropriately 1 cm. Risks and benefits have been conferred with the patient as well as the family, they wish to proceed. The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5. The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties. Spinal cord monitoring was induced. No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately. This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes. The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls. The patient's Mayfield tongue was fixated in the usual standard fashion. The patient was subsequently prepped and draped in the usual sterile fashion. Midline incision was extended from the base of the skull down to the C4 spinous process. Full thickness skin fascia developed. The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed. Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally. Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2. Good placement was seen both in the AP and lateral planes using fluoroscopy. Facet screws were then placed at C3. Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made. This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory. A 14 x 3.5 mm screws were then placed appropriately. Lateral masteries at C1 endplate were placed appropriately. The medial and lateral borders were demarcated with a Penfield. The great occipital nerve was retracted out the way. Starting point was made with a high-speed power bur and midline and lateral mass bilaterally. Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory. Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately. Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately. Once this was done, all end caps were appropriately torqued. This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment. It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access. Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2. The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3. Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements. The fascia was closed using interrupted #1 Vicryl suture figure-of-8. Superficial drain was placed appropriately. Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes. The subcutaneous tissues were closed using a #2-0 Vicryl suture. The dermal edges were approximated using staples. The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately. The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position. Mayfield tongues were subsequently released. No significant bleeding was appreciated. The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition. No complications arose." }

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

{ "text_length": 5394 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:, Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:, Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE: ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area. The patient was positioned in the modified beachchair position utilizing the Mayfield headrest. The left shoulder was propped posteriorly with a rolled towel. His head was secured to the Mayfield headrest. The left shoulder and upper extremity were then prepped and draped in the usual manner. A posterior lateral port was made for _____ the arthroscopic cannula. The scope was introduced into the glenohumeral joint. There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock. The labrum was adherent to the underlying capsule. The margin of the glenoid was frayed in this area. The biceps tendon was noted to be intact. The articular surface of the glenoid was fairly well preserved. The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head. The rotator cuff was visualized and noted to be intact. The axillary pouch was visualized and it was free of injury. There were some cartilaginous fragments within the axillary pouch. Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum. Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position. A second tack was then placed at about the 8 o'clock position. The labrum was then probed and was noted to be stable. With some general ranging of the shoulder, the tissue was pulled out from the tacks. An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position. Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area. At this point, it was deemed that an open Bankart arthroplasty was necessary. The arthroscopic instruments were removed. An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold. The skin incision was taken down through the skin. Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis. The deltopectoral fascia was identified. It was split at the deltopectoral interval and the deltoid was reflected laterally. The subdeltoid bursa was then removed with rongeurs. The conjoint tendon was identified. The deltoid and conjoint tendons were then retracted with a self-retaining retractor. The subscapularis tendon was identified. It was separated about a centimeter from its insertion, leaving the tissue to do sew later. The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially. This allowed for visualization of the capsule. The capsule was split near the humeral head insertion leaving a tag for repair. It was then split longitudinally towards the glenoid at approximately 9 o'clock position. This provided visualization of the glenohumeral joint. The friable labral and capsular tissue was identified. The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock. The sutures were passed through the labral capsular tissue and tied securely. At this point, the anterior glenoid rim had been recreated. The joint was then copiously irrigated with gentamicin solution and suctioned dry. The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture. This later was then copiously irrigated with gentamicin solution and suctioned dry. Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture. This later was then copiously irrigated as well and suctioned dry. The deltoid fascia was approximated with running #2-0 Vicryl suture. Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips. 0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia. The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied. The patient was then transferred to the recovery room in apparent satisfactory condition." }

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

{ "text_length": 4896 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. He states that he was in his usual state of health when he awoke one morning in January 2009. He had double vision. He states when he closed each eye, the double vision dissipated. The double vision entirely dissipated within one hour. He was able to drive. However, the next day he woke up and he had double vision again. Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation. He was seen by a primary care physician who sent him for an ophthalmologic evaluation. He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm. The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia. Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. He still does not drive. He also is not working due to the double vision. There is no temporal fluctuation to the double vision. More recently, over the past month, he has developed right supraorbital pain. It actually feels like there is pain under his right lid. He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system. Dr. X saw the patient on February 2, 2009, when he was in the emergency department. He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. MRV was negative and MRI of the brain with and without contrast was also negative. He also had an MRI of the orbit with and without contrast that was normal. His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis. He had left gaze diplopia. The pupils were equal, round, and reactive to light. His neurological examination was otherwise entirely normal. According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. There was also right medial rectus as well as possibly other extraocular abnormalities. I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:, He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife. He was an IT software developer, but he has been out of work for several months. He smokes less than a pack of cigarettes daily. He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: BP 124/76" }

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

{ "text_length": 3550 }

{ "text": "POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers. The patient has been asked to restrict the use of the * extremity for the next 24 hours." }

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

{ "text_length": 210 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Eyebrow ptosis.,2. Dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. Cervical facial aging with submental lipodystrophy.,OPERATION:,1. Hairline biplanar temporal browlift.,2. Quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3. Cervical facial rhytidectomy with purse-string SMAS elevation with submental lipectomy.,ASSISTANT: ,None.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE: , The patient was placed in a supine position and prepped with general endotracheal anesthesia. Local infiltration anesthesia with 1% Xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,Markings were made and fusiform ellipse of skin was resected from the upper eyelid. The lower limb of the fusiform ellipse was at the superior palpebral fold. A 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim. This was performed bilaterally and symmetrically and the skin was removed. Incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket. An incision was made over the superior orbital rim. Subperiosteal dissection was performed over the forehead. The dissection proceeded medially. The corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,Hemostasis was achieved with electrocautery in this fashion. A 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm. A subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid. The incision was made in the lower lid just beneath the lashline. Subcutaneous dissection was performed over the pretarsal and preseptal muscle. Dissection was then proceeded down to the inferior orbital rim. The arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim. The orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 Vicryl on a P2 needle. The upper eyelid incision was closed with a running subcuticular 6-0 Prolene suture bilaterally. The forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow. The head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,A lateral canthopexy was performed with 5-0 Prolene suture on a C1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid. The distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition. The lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides. Closure was performed with interrupted 6-0 silk suture for the lower lid. The eyebrow hairline brow lift was closed with interrupted 4-0 PDS suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 Prolene suture.,Attention then was directed to the cervical facial rhytidectomy and purse-string SMAS elevation with submental lipectomy. Incisions were made in preauricular area, postauricular area, mastoid and occipital area. Subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline. Submental lipectomy was performed through the incision in the submental crease. Fat was directly removed from the fascia.,Hemostasis was achieved with electrocautery. A SMAS elevation was performed with a purse-string suture of 2-0 PDS suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia. This was performed bilaterally and symmetrically. Hemostasis was achieved with electrocautery. The cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed. The skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,Closure was performed with interrupted 3-0 and 4-0 PDS suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 Prolene suture. Drains were placed prior to final closure. A 7-mm flat Jackson-Pratt was then secured with 3-0 silk suture. Dressing consisting of fluffs and Kerlix and a 4-inch Ace were applied to support mildly compressive dressing. Scleral eye protectors were removed. Maxitrol eye ointment was placed followed by Swiss therapy eye pads. The patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with Foley catheter and Pneumatic compression stockings, TED hose, two Jackson-Pratt drains, and an IV." }

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

{ "text_length": 5526 }

{ "text": "HISTORY OF PRESENT ILLNESS: , This is a followup for this 69-year-old African American gentleman with stage IV chronic kidney disease secondary to polycystic kidney disease. His creatinine has ranged between 4 and 4.5 over the past 6 months, since I have been following him. I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting him into classes. On his last visit, I really stressed the importance of him taking his medications adequately and not missing some of the doses, and he returns today with much better blood pressure control. He has also brought a machine at home, and states his blood pressure readings have been better. He has not gone to the transplant orientation class yet and has not been to dialysis education yet, and both of these I have discussed with him in the past. He also needs followup for his elevated PSA in the past, which has not been done for over 2 years and will likely need cardiac clearance if we ever are able to evaluate him for transplant.,REVIEW OF SYSTEMS: , Really negative. He continues to feel well. He denies any problems with shortness of breath, chest pain, swelling in his legs, nausea or vomiting, and his appetite remains good.,CURRENT MEDICATIONS:,1. Vytorin 10/40 mg one a day.,2. Rocaltrol 0.25 micrograms a day.,3. Carvedilol 12.5 mg twice a day.,4. Cozaar 50 mg twice a day.,5. Lasix 40 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: On exam, his blood pressure is 140/57, pulse 58, current weight is 67.1 kg, and again his blood pressure is markedly improved over his previous readings. GENERAL: He is a thin African American gentleman in no distress. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. I did not appreciate a murmur. ABDOMEN: Soft. He has a very soft systolic murmur at the left lower sternal border. No rubs or gallops. EXTREMITIES: No significant edema.,LABORATORY DATA: , Today indicates that his creatinine is 4.5 and stable, ionized calcium 8.5, intact PTH 458, and hemoglobin stable at 10.9. He is not on EPO yet. His UA has been negative.,IMPRESSION:,1. Chronic kidney disease, stage IV, secondary to polycystic kidney disease. His estimated GFR is 16 mL per minute. He has no uremic symptoms.,2. Hypertension, which is finally better controlled.,3. Metabolic bone disease.,4. Anemia.,RECOMMENDATION:, He needs a number of things done in terms of followup and education. I gave him more information again about dialysis education and transplant, and instructed him he needs to go to these classes. I also gave him websites that he can get on to find out more information. I have not made any changes in his medications. He is getting blood work done prior to his next visit with me. I will check a PSA on him but he needs to get back into see urology, as his last PSA that I see was 37 and this was from 02/05. He will see me back in about 4 to 6 weeks." }

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

{ "text_length": 2953 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE:,1. Nerve root decompression at L45 on the left side.,2. Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3. Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity. MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed. The patient was taken to the Operating room and was placed in the prone position. Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring. After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels. After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus. The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture. The #18-gauge needle was inserted off of midline. A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. Negative aspiration was carefully performed. Omnipaque 240 dye was then injected through the #16-gauge RK needle. The classical run off was noted. A filling defect was noted @ L45 nerve root on the left side. After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle. Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance. As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. The tip of the catheter was noted to be @ L45 level on the left side. After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side. After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape. The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected. The classical run off was noted in the lumbar region. Some lyses of adhesions were also visualized at this time with barbotage technique. Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted. Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.) The catheter was then capped with a bacterial filter. The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. This verified positive nerve root decompression. The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side. Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted. This patient did not report any problems and reported pain reduction." }

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

{ "text_length": 4534 }

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

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

{ "text_length": 2433 }

{ "text": "REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you." }

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

{ "text_length": 5245 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP: 122/86. Temp: 96.8. HR: 79. RR: 26. RAS: 100%.,HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. EOMs intact.,NECK: Supple without masses or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally,CARDIAC: Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES: No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT." }

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

{ "text_length": 1524 }

{ "text": "REASON FOR CONSULTATION:, Pneumothorax and subcutaneous emphysema.,HISTORY OF PRESENT ILLNESS: , The patient is a 48-year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.,PAST SURGICAL HISTORY: , Hernia repair and tonsillectomy.,ALLERGIES: , Penicillin.,MEDICATIONS: , Please see chart.,REVIEW OF SYSTEMS:, Not contributory.,PHYSICAL EXAMINATION:,GENERAL: Well developed, well nourished, lying on hospital bed in minimal distress.,HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.,NECK: Supple. Trachea is midline.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm.,ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.,EXTREMITIES: No clubbing, edema, or cyanosis.,SKIN: The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.,DIAGNOSTIC STUDIES:, As above.,IMPRESSION: , The patient is a 48-year-old male with subcutaneous emphysema and a small right-sided pneumothorax secondary to trauma. These are likely a result of either a parenchymal lung tear versus a small tracheobronchial tree rend.,RECOMMENDATIONS:, At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues." }

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

{ "text_length": 1887 }

{ "text": "Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee. He is unable to crawl and/or kneel. He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill. Stairs are a significant problem. His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice. He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS: ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.,PHYSICAL EXAMINATION: ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds. He does not appear to be in distress at this time. One could appreciate 1-2/4 intraarticular effusion. The range of motion is 0 to a 110 degrees of flexion. I could not appreciate any evidence of instability medial, lateral, anterior or posterior. Crepitus is noted with regards to range of motion testing. His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh. The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1. First report of injury.,2. July 17, 2002, x-rays of the right knee were negative.,3. Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4. August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial" }

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

{ "text_length": 2103 }

{ "text": "HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank \"lots of red wine.\" She states after vomiting, she felt \"fine through the night,\" but woke with more nausea and vomiting and diaphoresis. She states she has vomited approximately 20 times today and has also had some slight diarrhea. She denies any sore throat or cough. She states no one else at home has been ill. She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough. She notes no blood in her vomitus or stool. The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Temp is 37.6. Other vital signs are all within normal limits.,GENERAL: Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT: Head is normocephalic and atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. NECK: No enlarged anterior or posterior cervical lymph nodes. There is no meningismus.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,ABDOMEN: Active bowel sounds. Soft without any focal tenderness on palpation. There are no masses, guarding, or rebound noted.,SKIN: No rash.,EXTREMITIES: No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential. Hematocrit is 33.8, but the indices are normochromic and normocytic. BMP is remarkable for a random glucose of 147. All other values are unremarkable. LFTs are normal. Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea. She was given two capsules of Imodium with some apple juice, which she was able to keep down. The patient did feel well enough to be discharged home.,ASSESSMENT:, Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea. She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet. Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours. If she is unimproved in the next two days, she was urged to follow up with her PCP back home." }

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

{ "text_length": 2832 }

{ "text": "CHIEF COMPLAINT:,1. Extensive stage small cell lung cancer.,2. Chemotherapy with carboplatin and etoposide.,3. Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer. She is currently receiving treatment with carboplatin and etoposide. She completed her fifth cycle on 08/12/10. She has had ongoing back pain and was sent for a CT scan of the thorax. She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: ,The patient continues to have back pain some time she also take two pain pill. She received platelet transfusion the other day and reported mild fever. She denies any chills, night sweats, chest pain, or shortness of breath. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:" }

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

{ "text_length": 1061 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes, bilateral intraabdominal testes.,PROCEDURE: , Examination under anesthesia and laparoscopic right orchiopexy.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,FLUIDS RECEIVED: ,110 mL of crystalloid.,INTRAOPERATIVE FINDINGS: , Atrophic bilateral testes, right is larger than left. The left had atrophic or dysplastic vas and epididymis.,TUBES AND DRAINS: , No tubes or drains were used.,INDICATIONS FOR OPERATION: ,The patient is a 7-1/2-month-old boy with bilateral nonpalpable testes. Plan is for exploration, possible orchiopexy.,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, he was then palpated and again both testes were nonpalpable. Because of this, a laparoscopic approach was then elected. We then sterilely prepped and draped the patient, put an 8-French feeding tube in the urethra, attached to bulb grenade for drainage. We then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 Monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved Metzenbaum scissors. Once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens. Insufflation was then done with carbon dioxide up to 10 to 12 mmHg. We then evaluated. There was no bleeding noted. He had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized. The right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring. So, we elected to do an orchiopexy on the right side. Using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas. We then used the Maryland dissector to gently tease this tissue once it was incised. The gubernaculum was then divided with electrocautery and the laparoscopic scissors. We were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring. We then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery. We used the curved tenotomy scissors to make a subdartos pouch. Using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation. Using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction. Using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis. We then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic. We again evaluated the left side and found again that the vessels were quite short. The testis was more atrophic, and the vas was virtually nonexistent. We will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present. We then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 Monocryl, closed the infraumbilical incision with two Monocryl stay sutures to close the fascial sheath, and then used 4-0 Rapide to close the skin defects, and then using Dermabond tissue adhesives, we covered all incisions. At the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed. The patient had IV Toradol and was in stable condition upon transfer to recovery room." }

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

{ "text_length": 4391 }

{ "text": "CURRENT MEDICATIONS:, Lortab.,PREVIOUS MEDICAL HISTORY: , Cardiac stent in 2000.,PATIENT'S GOAL: , To eat again by mouth.,STUDY: ,A trial of Passy-Muir valve was completed to allow the patient to achieve hands-free voicing and also to improve his secretion management. A clinical swallow evaluation was not completed due to the severity of the patient's mucus and lack of saliva control.,The patient's laryngeal area was palpated during a dry swallow and he does have significantly reduced laryngeal elevation and radiation fibrosis. The further evaluate of his swallowing function is safety; a modified barium swallow study needs to be concluded to objectively evaluate his swallow safety, and to rule out aspiration. A trial of neuromuscular electrical stimulation therapy was completed to determine if this therapy protocol will be beneficial and improving the patient's swallowing function and safety.,For his neuromuscular electrical stimulation therapy, the type was BMR with a single mode cycle time is 4 seconds and 12 seconds off with frequency was 60 __________ with a ramp of 2 seconds, phase duration was 220 with an output of 99 milliamps. Electrodes were placed on the suprahyoid/submandibular triangle with an upright body position, trial length was 10 minutes. On a pain scale, the patient reported no pain with the electrical stimulation therapy.,FINDINGS: ,The patient was able to tolerate a 5-minute placement of the Passy-Muir valve. He reported no discomfort on the inhalation; however, he felt some resistance on exhalation. Instructions were given on care placement and cleaning of the Passy-Muir valve. The patient was instructed to buildup tolerance over the next several days of his Passy-Muir valve and to remove the valve at anytime or he is going to be sleeping or napping throughout the day. The patient's voicing did improve with the Passy-Muir valve due to decreased leakage from his trach secondary to finger occlusion. Mucus production also seemed to decrease when the Passy-Muir was placed.,On the dry swallow during this evaluation, the patient's laryngeal area is reduced and tissues around his larynx and showed radiation fibrosis. The patient's neck range of motion appears to be adequate and within normal limits.,A trial of neuromuscular electrical stimulation therapy:,The patient tolerating the neuromuscular electrical stimulation, we did achieve poor passive response, but these muscles were contracting and the larynx was moving upon stimulation. The patient was able to actively swallow with stimulation approximately 30% of presentation.,DIAGNOSTIC IMPRESSION: , The patient with a history of head and neck cancer status post radiation and chemotherapy with radiation fibrosis, which is impeding his swallowing abilities. The patient would benefit from outpatient skilled speech therapy for neuromuscular electrical stimulation for muscle reeducation to improve his swallowing function and safety and he would benefit from a placement of a Passy-Muir valve to have hands-free communication.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week to include neuromuscular electrical stimulation therapy, Passy-Muir placement and a completion of the modified barium swallow study.,SHORT-TERM GOALS (6 WEEKS):,1. Completion of modified barium swallow study.,2. The patient will coordinate volitional swallow with greater than 75% of the neuromuscular electrical stimulations.,3. The patient will increase laryngeal elevation by 50% for airway protection.,4. The patient will tolerate placement of Passy-Muir valve for greater than 2 hours during awaking hours.,5. The patient will tolerate therapeutic feedings with the speech and language pathologist without signs and symptoms of aspiration.,6. The patient will decrease mild facial restrictions to the anterior neck by 50% to increase laryngeal movement.,LONG-TERM GOALS (8 WEEKS):,1. The patient will improve secretion management to tolerable levels.,2. The patient will increase amount and oral consistency of p.o. intake tolerated without signs and symptoms of aspirations.,3. The patient will be able to communicate without using finger occlusion with the assistance of a Passy-Muir valve." }

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

{ "text_length": 4228 }

{ "text": "CHIEF COMPLAINT:, Weak and shaky.,HISTORY OF PRESENT ILLNESS:, The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspnea, and wheeze. She denies syncope, presyncope, or palpitations. Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:, She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:, She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:, Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:, She is a widow, lives alone. Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:, Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General: She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs: Blood pressure: 146/80. Pulse: 68. Weight: 147 pounds.,HEENT: Unremarkable.,Neck: Supple without JVD, adenopathy, or bruit.,Chest: Clear to auscultation.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft.,Extremities: No edema.,LABORATORY:, O2 sat 100% at rest and with exertion. Electrocardiogram was normal sinus rhythm. Nonspecific S-T segment changes. Chest x-ray pending.,ASSESSMENT/PLAN:,1. Dyspnea on exertion, uncertain etiology. Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors. We will have the patient sign a release of records so that we can review her previous history. Consider setting up for a stress test.,2. Hypertension, blood pressure is acceptable today. I am not certain as to what, if the patient’s is on any antihypertensive agents. We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3. History of diabetes. Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C. I have to obtain some further history and review records before proceeding with treatment recommendations." }

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

{ "text_length": 2974 }

{ "text": "OPERATION,1. Right upper lung lobectomy.,2. Mediastinal lymph node dissection.,ANESTHESIA,1. General endotracheal anesthesia with dual-lumen tube.,2. Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion. We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula. Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery. The 5th rib was counted, and the 6th interspace was entered. The lung was deflated. We identified the major fissure. We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery. Next, we used Bovie electrocautery to dissect the pleura off the lung. The pulmonary artery branches to the right upper lobe of the lung were identified. Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable. As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung. Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung. This was done with suture ligature in combination with clips. After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung. This likewise was ligated with a 0 silk. It was stick-tied with a 2-0 silk. It was then divided. Next we dissected out the bronchial branch to the right upper lobe of the lung. A curved Glover was placed around the bronchus. Next a TA-30 stapler was fired across the bronchus. The bronchus was divided with a #10-blade scalpel. The specimen was handed off. We next performed a mediastinal lymph node dissection. Clips were applied to the base of the feeding vessels to the lymph nodes. We inspected for any signs of bleeding. There was minimal bleeding. We placed a #32-French anterior chest tube, and a #32-French posterior chest tube. The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap. The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was transferred to the PACU in good condition." }

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

{ "text_length": 3084 }

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

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

{ "text_length": 1606 }

{ "text": "PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:, Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:, MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient. She was brought to the minor procedure area and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine. The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse. Approximately 6 mL of 5% phenol was injected in this location. At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles. Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL. The patient tolerated the procedure well and no complications were encountered." }

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

{ "text_length": 1511 }

{ "text": "TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast. Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures. ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis. The vertebral body heights and disc spaces are maintained. The central canal is patent. The pedicles and posterior elements are intact. The paravertebral soft tissues are within normal limits. The atlanto-dens interval and the dens are intact. The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities." }

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

{ "text_length": 712 }

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

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

{ "text_length": 3644 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,POSTOPERATIVE DIAGNOSIS: , Right hip osteoarthritis.,PROCEDURES PERFORMED: , Total hip replacement on the right side using the following components:,1. Zimmer trilogy acetabular system 10-degree elevated rim located at the 12 o'clock position.,2. Trabecular metal modular acetabular system 48 mm in diameter.,3. Femoral head 32 mm diameter +0 mm neck length.,4. Alloclassic SL offset stem uncemented for taper.,ANESTHESIA: , Spinal.,DESCRIPTION OF PROCEDURE IN DETAIL:, The patient was brought into the operating room and was placed on the operative table in a lateral decubitus position with the right side up. After review of allergies, antibiotics were administered and time out was performed. The right lower extremity was prepped and draped in a sterile fashion. A 15 cm to 25 cm in length, an incision was made over the greater trochanter. This was angled posteriorly. Access to the tensor fascia lata was performed. This was incised with the use of scissors. Gluteus maximus was separated. The bursa around the hip was identified, and the bleeders were coagulated with the use of Bovie. Hemostasis was achieved. The piriformis fossa was identified, and the piriformis fossa tendon was elevated with the use of a Cobb. It was detached from the piriformis fossa and tagged with 2-0 Vicryl. Access to the capsule was performed. The capsule was excised from the posterior and superior aspects. It was released also in the front with the use of a Mayo scissors. The hip was then dislocated. With the use of an oscillating saw, the femoral neck cut was performed. The acetabulum was then visualized and debrided from soft tissues and osteophytes. Reaming was initiated and completed for a 48 mm diameter cap without complications. The trial component was put in place and was found to be stable in an anatomic position. The actual component was then impacted in the acetabulum. A 10-degree lip polyethylene was also placed in the acetabular cap. Our attention was then focused to the femur. With the use of a cookie cutter, the femoral canal was accessed. The broaching process was initiated for No.4 trial component. Trialing of the hip with the hip flexed at 90 degrees and internally rotated to 30 degrees did not demonstrate any obvious instability or dislocation. In addition, in full extension and external rotation, there was no dislocation. The actual component was inserted in place and hemostasis was achieved again. The wound was irrigated with normal saline. The wound was then closed in layers. Before performing that the medium-sized Hemovac drain was placed in the wound. The tensor fascia lata was closed with 0 PDS and the wound was closed with 2-0 Monocryl. Staples were used for the skin. The patient recovered from anesthesia without complications.,EBL: , 50 mL.,IV FLUIDS: , 2 liters.,DRAINS: , One medium-sized Hemovac.,COMPLICATIONS: , None.,DISPOSITION: , The patient was transferred to the PACU in stable condition. She will be weightbearing as tolerated to the right lower extremity with posterior hip precautions. We will start the DVT prophylaxis after the removal of the epidural catheter." }

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

{ "text_length": 3211 }