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{ "text": "ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:, This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs. She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted. Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery. She was interested in participating in the artificial disk replacement study and was entered into that study. She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007. She has done well postoperatively with a sensation of right arm pain and numbness in her fingers. She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well. She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment. She will contact our office prior to her appointment if she has problems. Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n. #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n. #60 with 1 refill." }

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

{ "text_length": 1412 }

{ "text": "CHIEF COMPLAINT:, Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:, Vicodin.,ALLERGIES:, None.,PHYSICAL EXAM: ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus.,Lungs: Clear.,Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign.,Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION: , Headache, improved. Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram." }

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

{ "text_length": 1545 }

{ "text": "CHIEF COMPLAINT:, One-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the last steroid injection that she had with Dr. XYZ really did help. The patient denies any shortness of breath or cough. Has no nausea, vomiting, abdominal pain. No diarrhea or constipation. She states her appetite is good. She clears her plate at noon. She has had no fevers, chills, or sweats. The friend with her states she is doing very well. Seems to eat excellently at noontime, despite this, the patient continues to lose weight. When I asked her what she eats for breakfast and for supper, she states she really does not eat anything. Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time. She states she is really not hungry the rest of the time except at lunchtime. She denies any fevers, chills, or sweats. We did do some lab work at the last office visit and CBC was essentially normal. Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3. This is fairly stable for her. Liver enzymes were normal. TSH was normal. Free albumin was normal at 23. She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS: ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:, The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:, As above in HPI.,PHYSICAL EXAM:,General: This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face. States are clothes are fitting more loosely.,Vital Signs: Weight: 123, down 5 pounds from last month and down 11 pounds from May 2004. Blood pressure: 128/62. Pulse: 60. Respirations: 20. Temperature: 96.8.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft and nontender, nondistended with positive bowel sounds. No organomegaly or masses are appreciated.,Extremities: Free of edema.,ASSESSMENT:,1. Unintentional weight loss. I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2. Depression, doing well.,3. Paranoia, doing well.,4. Dementia, stable.,5. Osteoarthritis of the knees, pain is much improved.,PLAN:,1. Continue on current medications.,2. I did call and talk with doctor at hospital. We discussed different options. We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time. Connie will weigh the patient once a week and I will go ahead and see the patient in one month. We can see how she is doing at that time. If she continues to lose weight despite eating better, then I think we will need to do further evaluation." }

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

{ "text_length": 3789 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Hypermenorrhea.,2. Pelvic pain.,3. Infertility.,POSTOPERATIVE DIAGNOSES:,1. Enlarged fibroid uterus.,2. Infertility.,3. Pelvic pain.,4. Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1. Dilatation and curettage.,2. Laparoscopy.,3. Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile. The cervix is nulliparous without lesions. Adnexal examination was negative for masses.,PROCEDURE: ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner. After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum. Uterus sounded to a depth of 10.5 cm. Endocervical canal was progressively dilated with Hanks dilators to #20-French. A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis. A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air. A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity. The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted. The laparoscope was then inserted through the trocar with visualization of the pelvic contents. In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas. The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria. The ovaries also appeared normal bilaterally. The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area. An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still. Both fallopian tubes apparently were blocked. The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum. The patient tolerated the procedure well. Instruments were removed from the vaginal vault and the abdomen. Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures. Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition." }

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

{ "text_length": 2767 }

{ "text": "CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain: Localized to the bilateral knees right worse than left.,Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. ,Duration: Months.,Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. ,Hip Pain: None. ,Back pain: None. ,Radicular type pain: None. ,Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:, No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living. ,REVIEW OF SYSTEMS:, No change.,Constitutional: Good appetite and energy. No fever. No general complaints.,HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion.,GI:" }

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

{ "text_length": 1496 }

{ "text": "PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had \"zig-zag lines\" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:, Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY: ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:, On examination, the patient was pleasant. She was able to speak English fairly well. Her blood pressure was 130/84. Heart rate was 80. Respiratory rate was 16. Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able to walk normally. Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable. She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:, The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. Her diagnosis is consistent with vestibular migraine. I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet. I gave her instructions including a list of foods times, which worsen migraine. I reviewed this information for more than half the clinic visit. I would like to start her on amitriptyline at a dose of 10 mg at time. She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms." }

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

{ "text_length": 4132 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:, Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:, Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,The patient is a 41-year-old female who presented to Dr. X's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,PROCEDURE: , After informed consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite. After IV sedation was given, the patient was prepped and draped in normal sterile fashion. A radial incision was made in the right lateral breast with a #10 blade scalpel. The needle was brought into the field. An Allis was used to grasp the breast mass and breast tissue using the #10 scalpel. The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen.,Hemostasis was then obtained with electrobovie cautery. The skin was then closed with #4-0 Monocryl in a running subcuticular fashion. Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable condition." }

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

{ "text_length": 1602 }

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

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

{ "text_length": 5065 }

{ "text": "CHILD PHYSICAL EXAMINATION,VITAL SIGNS: Birth weight is ** grams, length **, occipitofrontal circumference **. Character of cry was lusty.,GENERAL APPEARANCE: Well.,BREATHING: Unlabored.,SKIN: Clear. No cyanosis, pallor, or icterus. Subcutaneous tissue is ample.,HEAD: Normal. Fontanelles are soft and flat. Sutures are opposed.,EYES: Normal with red reflex x2.,EARS: Patent. Normal pinnae, canals, TMs.,NOSE: Patent nares.,MOUTH: No cleft.,THROAT: Clear.,NECK: No masses.,CHEST: Normal clavicles.,LUNGS: Clear bilaterally.,HEART: Regular rate and rhythm without murmur.,ABDOMEN: Soft, flat. No hepatosplenomegaly. The cord is three vessel.,GENITALIA: Normal ** genitalia **with testes descended bilaterally.,ANUS: Patent.,SPINE: Straight and without deformity.,EXTREMITIES: Equal movements.,MUSCLE TONE: Good.,REFLEXES: Moro, grasp, and suck are normal.,HIPS: No click or clunk." }

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

{ "text_length": 909 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Right upper eyelid squamous cell carcinoma.,PROCEDURE PERFORMED: , Excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,COMPLICATIONS: ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA:, Local with sedation.,INDICATION:, The patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. He was anesthetized with a combination of 2% lidocaine and 0.5% Marcaine with Epinephrine on both upper eyelids. The area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. This was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. The resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. Following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. The specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. Meticulous hemostasis was obtained with Bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. The left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. An eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to PACU in good condition." }

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

{ "text_length": 2190 }

{ "text": "CHIEF COMPLAINT:,1. Infection.,2. Pelvic pain.,3. Mood swings.,4. Painful sex.,HISTORY OF PRESENT ILLNESS:, The patient is a 29-year-old female who is here today with the above-noted complaints. She states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past. She is requesting antibiotics. She has been squeezing them and some of them are very bruised and irritated. She also states that she is having significant pelvic pain and would like to go back and see Dr. XYZ again. She also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all. She also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off. She states she does not wish to be on any medication at the current time. She otherwise states that sex is so painful that she is unable to have sex with her husband, even though she \"wants to.\",PAST MEDICAL HISTORY:, Significant for cleft palate.,ALLERGIES:, She is allergic to Lortab.,CURRENT MEDICATIONS:, None.,REVIEW OF SYSTEMS:, Please see history of present illness.,Psychiatric: She has had some suicidal thoughts, but no plans. She denies being suicidal at the current time.,Cardiopulmonary: She has not had any chest pain or shortness of breath.,GI: Denies any nausea or vomiting.,Neurological: No numbness, weakness or tingling.,PHYSICAL EXAMINATION:,General: The patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,Vital signs: Weight: 160 pounds. Blood pressure: 100/60. Pulse: 62.,Psychiatric: I did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,Extremities: Her inner thighs are covered with multiple areas of folliculitis and mild abscesses. They are bruised from her squeezing them. We talked about that in detail.,ASSESSMENT:,1. Folliculitis.,2. Pelvic pain.,3. Mood swings.,4. Dyspareunia.,PLAN:,1. I would like her to go to the lab and get a CBC, chem-12, TSH and UA.,2. We will put her on cephalexin 500 mg three times a day.,3. We will send her back to see Dr. XYZ regarding the pelvic pain per her request.,4. We will get her an appointment with a psychiatrist for evaluation and treatment.,5. She is to call if she has any further problems or concerns. Otherwise I will see her back for her routine care or sooner if there are any further issues." }

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

{ "text_length": 2610 }

{ "text": "OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating room table. The patient was prepped and draped in usual sterile fashion. An incision was made in the groin crease overlying the internal ring. This incision was about 1.5 cm in length. The incision was carried down through the Scarpa's layer to the level of the external oblique. This was opened along the direction of its fibers and carried down along the external spermatic fascia. The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free. A hernia sac was identified and the testicle was located. Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring. This was performed by incising the transversalis fascia circumferentially. The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity. Care was taken not to injure the testicular vessels. Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance. The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high. This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum. The testicle was viable. This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum. A small 1 cm incision was made in the anterior superior scrotal wall. Dissection was carried down through the dartos layer. A subdartos pouch was formed with blunt dissection. The hemostat was then pushed against the tissues and this tissue was divided. The hemostat was then passed through the incision. A Crile hemostat was passed back up into the inguinal canal. The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision. The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle. The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture. Benzoin and a Steri-Strip were placed. Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly. This was done with 2 to 3 interrupted 3-0 silk sutures. The external oblique was then closed with interrupted 3-0 silk suture. The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch. Benzoin and Steri-Strip were applied. The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition." }

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

{ "text_length": 3109 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:, Left ovarian lesion.,PROCEDURE PERFORMED: ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:, General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:, None.,FINDINGS:, The labia and perineum were within normal limits. The hymen was found to be intact. Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled. There were a few calcifications on the surface of the mass. The right ovary and fallopian tube appeared normal. There was no evidence of endometriosis. The uterus appeared normal in size. There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm. She does complain of minimal discomfort. Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position. A 1 cm skin incision was made in the infraumbilical vault. While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated. This was done using appropriate flow and volume of CO2. The #11 step trocar was then placed without difficulty. The above findings were confirmed. A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization. Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall. Both #12 step ports were done under direct visualization. Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating. The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision. The skin was extended around this incision and the fascia was extended using the Mayo scissors. The specimen was removed intact in the Endocatch bag through this site. Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic. All the port sites were hemostatic as well. The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle. The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion. The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated. Steri-Strips were placed on each of the incisions. The patient tolerated the procedure well. Sponge, lap, and needle count were x2. She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her." }

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

{ "text_length": 2994 }

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

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

{ "text_length": 4267 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.,PAST MEDICAL HISTORY:, She claims no chronic illnesses.,PAST SURGICAL HISTORY: , She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.,MEDICATIONS: , She takes no medications on a regular basis,ALLERGIES: , She is allergic to Keflex and has skin sensitivity to Steri-Strips.,SOCIAL HISTORY: ,The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and swelling.,REVIEW OF SYSTEMS: ,Significant for recent weight gain, occasional skin rashes. The remainder of her systems negative.,PHYSICAL EXAMINATION,GENERAL: The patient is 4 foot 10 inches tall, weighs 110 pounds.,EXTREMITIES: She ambulates with some difficulty with a marked limp on the right side. Inspection of the knee reveals a significant effusion in the knee. She has difficulty with passive range of motion of the knee secondary to pain. She does have tenderness to palpation at the medial joint line and has a positive Lachman's exam.,NEUROVASCULAR: She is neurovascularly intact.,IMPRESSION: , Right knee injury suggestive of a recurrent anterior cruciate ligament tear, possible internal derangement.,PLAN: , The patient will be referred for an MRI of the right knee to evaluate the integrity of her revision ACL graft. In the meantime, she will continue to use ice as needed. Moderate her activities and use crutches. She will follow up as soon as the MRI is performed." }

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

{ "text_length": 2455 }

{ "text": "IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS: ,The patient was very sleepy this morning, only minimally cooperative with interview. Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone. The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury. The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain. His ER course is notable for yelling, spitting, and striking multiple staff members. The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others. On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. He was contrite about the violence. When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium. He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. She reports that she has been in contact with him since his arrival in our facility and reports that he is \"back to normal.\" She denies feeling that he currently represents a threat to her or her five children. She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. The patient denies any outpatient mental health treatment before or since this hospitalization. He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:, Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:, From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known. His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. He lives with his wife and children. He has a history of domestic violence, but not recently. Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:, Records indicate a previous history of methamphetamine and alcohol abuse/dependence. The wife states that he has not consumed either since 12/07. Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY: ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude: The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor: There is no obvious psychomotor agitation or retardation. There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect: His affect is notably restricted probably due to the fact that he is sleepy.,Mood: Describes his mood as \"okay.\",Speech: Speech is normal rate, volume, and tone.,Thought Processes: His thought processes appear to be linear.,Thought Content: His thought content is notable for his expressions of contrition about violence at Hospital last night. He denies suicidal or homicidal ideation.,Cognitive Assessment: Cognitively, he is alert and oriented to person, place, and date but not situation. Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight: His insight and judgment are both appear to be improving.,Assets: Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations: Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION: ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium. He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved. He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I: Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.) Rule out bipolar affective disorder.,AXIS II: Deferred.,AXIS III: Chronic pain status post back surgery.,AXIS IV: Appears to be moderate. He is currently on medical leave from his job.,AXIS V: Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:, Three days.,PLAN:, I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications. The patient will be placed on CIWA protocol given that one of the medications he overused was Valium. Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge. I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management." }

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

{ "text_length": 7056 }

{ "text": "REASON FOR CONSULT: , I was asked to see this patient with metastatic non-small-cell lung cancer, on hospice with inferior ST-elevation MI.,HISTORY OF PRESENT ILLNESS: , The patient from prior strokes has expressive aphasia, is not able to express herself in a clear meaningful fashion. Her daughter who accompanies her is very attentive whom I had met previously during drainage of a malignant hemorrhagic pericardial effusion last month. The patient has been feeling well for the last several weeks, per the daughter, but today per the personal aide, became agitated and uncomfortable at about 2:30 p.m. At about 7 p.m., the patient began vomiting, was noted to be short of breath by her daughter with garbled speech, arms flopping, and irregular head movements. Her daughter called 911 and her symptoms seemed to improve. Then, she began vomiting. When the patient's daughter asked her if she had chest pain, the patient said yes.,She came to the emergency room, an EKG showed inferior ST-elevation MI. I was called immediately and knowing her history, especially, her hospice status with recent hemorrhagic pericardial effusion, I felt thrombolytic was contraindicated and she would not be a candidate for aggressive interventional therapy with PCI/CABG. She was begun after discussion with the oncologist, on heparin drip and has received morphine, nitro, and beta-blocker, and currently states that she is pain free. Repeat EKG shows normalization of her ST elevation in the inferior leads as well as normalization of prior reciprocal changes.,PAST MEDICAL HISTORY: , Significant for metastatic non-small-cell lung cancer. In early-to-mid December, she had an admission and was found to have a malignant pericardial effusion with tamponade requiring urgent drainage. We did repeat an echo several weeks later and that did not show any recurrence of the pericardial effusion. She is on hospice from the medical history, atrial fibrillation, hypertension, history of multiple CVA.,MEDICATIONS: , Medications as an outpatient:,1. Amiodarone 200 mg once a day.,2. Roxanol concentrate 5 mg three hours p.r.n. pain.,ALLERGIES: ,CODEINE. NO SHRIMP, SEAFOOD, OR DYE ALLERGY.,FAMILY HISTORY: , Negative for cardiac disease.,SOCIAL HISTORY: , She does not smoke cigarettes. She uses alcohol. No use of illicit drugs. She is divorced and lives with her daughter. She is a retired medical librarian from Florida.,REVIEW OF SYSTEMS: ,Unable to be obtained due to the patient's aphasia.,PHYSICAL EXAMINATION: , Height 5 feet 3, weight of 106 pounds, temperature 97.1 degrees, blood pressure ranges from 138/82 to 111/87, pulse 61, respiratory rate 22. O2 saturation 100%. On general exam, she is an elderly woman with now marked aphasia, which per her daughter waxes and wanes, was more pronounced and she nods her head up and down when she says the word, no, and conversely, she nods her head side-to-side when she uses the word yes with some discordance in her head gestures with vocalization. HEENT shows the cranium is normocephalic and atraumatic. She has dry mucosal membrane. She now has a right facial droop, which per her daughter is new. Neck veins are not distended. No carotid bruits visible. Skin: Warm, well perfused. Lungs are clear to auscultation anteriorly. No wheezes. Cardiac exam: S1, S2, regular rate. No significant murmurs. PMI is nondisplaced. Abdomen: Soft, nondistended. Extremities: Without edema, on limited exam. Neurological exam seems to show only the right facial droop.,DIAGNOSTIC/LABORATORY DATA: , EKGs as reviewed above. Her last ECG shows normalization of prior ST elevation in the inferior leads with Q waves and first-degree AV block, PR interval 280 milliseconds. Further lab shows sodium 135, potassium 4.2, chloride 98, bicarbonate 26, BUN 9, creatinine 0.8, glucose 162, troponin 0.17, INR 1.27, white blood cell count 1.3, hematocrit 31, platelet count of 179.,Chest x-ray, no significant pericardial effusion.,IMPRESSION: , The patient is a 69-year-old woman with metastatic non-small-cell lung cancer with a recent hemorrhagic pericardial effusion, now admitted with cerebrovascular accident and transient inferior myocardial infarction, which appears to be canalized. I will discuss this in detail with the patient and her daughter, and clearly, her situation is quite guarded with likely poor prognosis, which they are understanding of.,RECOMMENDATIONS:,1. I think it is reasonable to continue heparin, but clearly she would be at risk for hemorrhagic pericardial effusion recurrence.,2. Morphine is appropriate, especially for preload reduction and other comfort measures as appropriate.,3. Would avoid other blood thinners including Plavix, Integrilin, and certainly, she is not a candidate for a thrombolytic with which the patient and her daughter are in agreement with after a long discussion.,Other management as per the medical service. I have discussed the case with Dr. X of the hospitalist service who will be admitting the patient." }

[ { "label": " Hospice - Palliative Care", "score": 1 } ]

{ "text_length": 5031 }

{ "text": "CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells. It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course. It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held. This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects. In accordance, this requires more frequency consultation and coordination with the medical oncologist. Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470." }

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

{ "text_length": 1204 }

{ "text": "REASON FOR CONSULTATION: , Glioma.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982. She underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery. She did well for the next 10 years or so, and developed Parkinson disease, possibly related to radiation therapy. She has been followed by neurology, Dr. Z, to treat seizure activity. She has a vagal stimulator in place to help control her seizure activity.,Over the last few months, she has had increasing weakness on the right side. She has been living in a nursing home. She has not been able to walk, and she has not been able to write for the past three to four years.,MRI scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region. There was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,Surgery was performed during this admission to remove some of the posterior part of the tumor. She tolerated the procedure well. She has noticed no worsening or improvement in her weakness. Pathology shows a low- to intermediate-grade glioma. The second opinion by Dr. A is still pending.,The patient is feeling well today. She is not having headache, and reports no new neurologic symptoms. She has not had leg swelling, cough, shortness of breath, or chest pain.,CURRENT MEDICATIONS: ,1. Ambien p.r.n. ,2. Vicodin p.r.n. ,3. Actonel every Sunday. ,4. Colace. ,5. Felbatol 1200 mg b.i.d. ,6. Heparin injections for prophylaxis. ,7. Maalox p.r.n. ,8. Mirapex 0.5 mg t.i.d. ,9. Protonix 40 mg daily. ,10. Tylenol p.r.n. ,11. Zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime. ,12. She has Zofran p.r.n., albuterol inhaler q.i.d., and Aggrenox, which she is to start.,The rest of the history is mostly from the chart.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,PAST MEDICAL HISTORY: ,1. Parkinson's, likely secondary to radiation therapy.,2. History of prior stroke.,3. Seizure disorder secondary to her brain tumor.,4. History of urinary incontinence.,5. She has had hip fractures x2, which have required surgical pinning.,6. Appendectomy.,7. Cholecystectomy.,SOCIAL HISTORY:, Shows that she does not smoke cigarettes or drink alcohol. She lives in a nursing home.,FAMILY HISTORY:, Shows a family history of breast cancer.,PHYSICAL EXAMINATION:, ,GENERAL: Today, she is sitting up in the chair, alert, and appropriate. She tends to lean towards the right. The right arm and hand are noticeably weaker than the left. She is quite thin.,VITAL SIGNS: Temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,HEENT: There is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place. The oropharynx shows no thrush or mucositis.,LUNGS: Clear bilaterally to auscultation.,CARDIAC: Exam shows regular rate.,ABDOMEN: Soft.,EXTREMITIES: No peripheral edema or evidence of deep venous thrombosis (DVT) is noted on the lower extremities.,IMPRESSION AND PLAN:, Progressive low-grade glioma, now more than 20 years since initially diagnosed. She is status post craniotomy for debulking and has done well with the surgery.,We reviewed the phase II trials that have used Temodar in the setting of grade 2 gliomas. Although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity. We discussed using Temodar after she heals from her surgery. Toxicities would include fatigue, nausea, and myelosuppression primarily." }

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

{ "text_length": 3842 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Postoperative wound infection.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1. Postoperative wound infection. There was an intraperitoneal foreign body.,2. Left gluteal abscess.,3. Intraperitoneal pigtail catheter.,PROCEDURES,1. Incision and drainage (I&D) of gluteal abscess.,2. Removal of pigtail catheter.,3. Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed. Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion. The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward. I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism. It came out without any difficulty. Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion. My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision. I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen. Very carefully, I started dividing the fascia. Of course, there were several small bowel loops adhered to the area. The dissection was quite tedious for a while. Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract. I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia. There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination. Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula. The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS. The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied. A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area. The patient tolerated the procedure well. Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating." }

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

{ "text_length": 3420 }

{ "text": "HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity . , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. , ,MEDICATIONS: , Claritin for allergic rhinitis. , ,ALLERGIES: , None. , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2. He is sitting upright, alert and oriented, and in no acute distress. Skin is warm and dry. Gross neurologic examination is normal. ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes. Neck: Full range of motion with no adenopathy or thyromegaly. Cardiovascular: Regular rate and rhythm. Lungs: Clear. Abdomen: Soft." }

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

{ "text_length": 1460 }

{ "text": "REASON FOR VISIT:, Six-month follow-up visit for CAD.,He is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and DJD.,He has been having a lot of pain in his back and pain in his left knee. He is also having trouble getting his nerves under control. He is having stomach pains and occasional nausea. His teeth are bad and need to be pulled.,He has been having some chest pains, but overall he does not sound too concerning. He does note some more shortness of breath than usual. He has had no palpitations or lightheadedness. No problems with edema.,MEDICATIONS:, Lipitor 40 mg q.d., metoprolol 25 mg b.i.d., Plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, Lorcet 10/650-given a 60 pill prescription, and Xanax 0.5 mg b.i.d-given a 60 pill prescription.,REVIEW OF SYSTEMS: , Otherwise unremarkable.,PEX:, BP: 140/78. HR: 65. WT: 260 pounds (which is up one pound). There is no JVD. No carotid bruit. Cardiac: Regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border. Lungs: Clear. Abdomen: Mildly tender throughout the epigastrium.,Extremities: No edema.,EKG:, Sinus rhythm, left axis deviation, otherwise unremarkable.,Echocardiogram (for dyspnea and CAD): Normal systolic and diastolic function. Moderate LVH. Possible gallstones seen.,IMPRESSION:,1. CAD-Status post anterior wall MI 07/07 and was found to a have multivessel CAD. He has a stent in his LAD and his obtuse marginal. Fairly stable.,2. Dyspnea-Seems to be due to his weight and the disability from his knee. His echocardiogram shows no systolic or diastolic function.,3. Knee pain-We well refer to Scotland Orthopedics and we will refill his prescription for Lorcet 60 pills with no refills.,4. Dyslipidemia-Excellent numbers today with cholesterol of 115, HDL 45, triglycerides 187, and LDL 33, samples of Lipitor given.,5. Panic attacks and anxiety-Xanax 0.5 mg b.i.d., 60 pills with no refills given.,6. Abdominal pain-Asked to restart his omeprazole and I am also going to reduce his aspirin to 81 mg q.d.,7. Prevention-I do not think he needs to be on the Plavix any more as he has been relatively stable for two years.,PLAN:,1. Discontinue Plavix.,2. Aspirin reduced to 81 mg a day.,3. Lorcet and Xanax prescriptions given.,4. Refer over to Scotland Orthopedics.,5. Peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted." }

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

{ "text_length": 2504 }

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

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

{ "text_length": 2061 }

{ "text": "IMPRESSION:, Abnormal electroencephalogram revealing generalized poorly organized slowing, with more prominent slowing noted at the right compared to the left hemisphere head regions and rare sharp wave activity noted bilaterally, somewhat more prevalent on the right. Clinical correlation is suggested." }

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

{ "text_length": 305 }

{ "text": "REASON FOR VISIT: , Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation. She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS:, She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007. She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0. We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine. Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes. She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes. She does experience some leakage with coughing. She wears the pad on a daily basis. She does not think that her bladder has changed much since we saw her last. With respect to her thinking and memory, she reports no problems at this time. She reports no headaches at this time. With respect to her walking and balance, she says that it feels worse. In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs. She states that her leg often feel like elastic and she experiences a tingling radiculopathy. She says that this tingling is constant and at times painful. She feels that she is walking slower for this reason. She does not use the cane at this time. Most of the time, she is able to walk over uneven surfaces. She is able to walk up and down stairs and has no trouble getting in and out of a car.,MEDICATIONS:, Rhinocort 32 mg two sprays a day, Singulair 10 mg once a day, Xyzal 5 mg in the morning, Spiriva once a day, Advair twice a day, Prevacid 30 mg twice a day, Os-Cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,MAJOR FINDINGS:, On exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty. She is well developed, well nourished, and kempt.,The shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,Mental Status: Assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge. Her Mini-Mental Status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,Cranial Nerves: Extraocular movements are somewhat inhibited. She does not display any nystagmus at this time. Facial movement, hearing, head turning, tongue, and palate movement are all intact.,Gait: Assessed using the Tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,ASSESSMENT:, Ms. ABC has been experiencing difficulty with walking over the past several months.,PROBLEMS/DIAGNOSES:,1. Hydrocephalus.,2. Cervical stenosis and retrolisthesis.,3. Neuropathy in the legs.,PLAN: , Before we recommend anything more, we would like to get a hold of the notes from Dr. XYZ to try to come up with a concrete plan as to what we can do next for Ms. ABC. We believe that her walking is most likely not being effected by the hydrocephalus. We would like to see her back in clinic in two and a half months or so. We also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one. I suggested that she use the cane at her on discretion." }

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

{ "text_length": 3660 }

{ "text": "HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES: ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity. The left median sensory distal latency is prolonged with an attenuated evoked response amplitude. The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude. The right median motor distal latency and evoked response amplitude is normal. Left ulnar motor and sensory and left radial sensory responses are normal. Left median F-wave is normal.,NEEDLE EMG:, Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles. It revealed spontaneous activity in the left abductor pollicis brevis muscle. There is increased insertional activity in the right first dorsal interosseous muscle. Both interosseous muscles showed signs of reinnervation. Left extensor digitorum communis muscle showed evidence of reduced recruitment. Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal. It reveals the following: A left median neuropathy at the wrist consistent with carpal tunnel syndrome. Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies. This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ. She will follow up with Dr. XYZ with respect to treatment of the above conditions." }

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

{ "text_length": 2046 }

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

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

{ "text_length": 12574 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes. Ultrasound showed metastasis to be high in the left inguinal canal. The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum. Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses. There is a hernia on the left side. The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table. General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically. A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision. An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia. External ring was exposed with dissection as well. The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal. The testes were freed with dissection by removing cremasteric and spermatic fascia. The hernia sac was separated from the cord, twisted and suture ligated at the internal ring. Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring. However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided. This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel. The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures. The skin was approximated with interrupted #5-0 chromic catgut sutures. Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good. Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture. Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion. However, on this side, there was no inguinal hernia. The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side. The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure. Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision. The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition. Instrument and sponge counts were correct. There were no apparent complications. Estimated blood loss was less than 20 to 30 mL." }

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

{ "text_length": 3807 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:, None.,BRIEF HISTORY:, This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.,OPERATIVE FINDINGS:, The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE: ,The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit." }

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

{ "text_length": 4681 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,POSTOPERATIVE DIAGNOSES:,1. Left spermatocele.,2. Family planning.,PROCEDURE PERFORMED:,1. Left spermatocelectomy/epididymectomy.,2. Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION: ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort. The patient also has family status complete and desired infertility. The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was moved to the operating room. A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach. A #15 blade was used to make a transverse incision on the left hemiscrotum. Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field. The left testicle was examined. A large spermatocele was noted. Metzenbaum scissors were used to dissect the tissue around the left spermatocele. Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis. Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery. Electrocautery was used to confirm excellent hemostasis. Attention was then turned to the more proximal aspect of the cord. The vas deferens was palpated and dissected free with Metzenbaum scissors. Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends. Testicle was placed back in the scrotum in appropriate anatomic position. The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic. Attention was then turned to the right side. The vas was palpated in the scrotum. A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field. A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat. Two ends were hemostated with hemostats and divided with Metzenbaum scissors. Lumen was coagulated with electrocautery. Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum. A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision. Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied. The patient was sent to Recovery in stable condition. He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain. The patient is to followup with Dr. X in seven days." }

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

{ "text_length": 3523 }

{ "text": "PROCEDURES: , Total knee replacement.,PROCEDURE DESCRIPTION:, The patient was bought to the operating room and placed in the supine position. After induction of anesthesia, a tourniquet was placed on the upper thigh. Sterile prepping and draping proceeded. The tourniquet was inflated to 300 mmHg. A midline incision was made, centered over the patella. Dissection was sharply carried down through the subcutaneous tissues. A median parapatellar arthrotomy was performed. The lateral patellar retinacular ligaments were released and the patella was retracted laterally. Proximal medial tibia was denuded, with mild release of medial soft tissues. The ACL and PCL were released. The medial and lateral menisci and suprapatellar fat pad were removed. These releases allowed for anterior subluxation of tibia. An extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia. Its alignment was checked with the rod and found to be adequate. The tibia was then allowed to relocate under the femur.,An intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques. An anterior rough cut was made. The distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed. The distal cut was performed.,A spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment. Femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made. The notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made. The trial femoral component was impacted onto the distal femur and found to have an excellent fit. A trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes. Appropriate rotation of the tibial component was identified and marked. The trials were removed and the tibia was brought forward again. The tibial plate size was checked and the plate was pinned to plateau. A keel guide was placed and the keel was then made. The femoral intramedullary hole was plugged with bone from the tibia. The trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,The patella was held in a slightly everted position with knee in extension. Patellar width was checked with calipers. A free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers. Sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy. Any excess lateral patellar bone was recessed. The trial patellar component was placed and found to have adequate tracking. The trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried. The cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted. The excess cement was removed from the gutters and anterior and posterior parts of the knee. The knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened. Once the cement had hardened, the tourniquet was deflated. The knee was dislocated again, and any excess cement was removed with an osteotome. Thorough irrigation and hemostasis were performed. The real polyethylene component was placed and pinned. Further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed. The arthrotomy was closed using 0 Ethibond and Vicryl sutures. The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures. The skin was sealed with staples. Xeroform and a sterile dressing were applied followed by a cold-pack and Ace wrap. The patient was transferred to the recovery room in stable condition, having tolerated the procedure well." }

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

{ "text_length": 4397 }

{ "text": "HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. He is also an ex-smoker. He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. His pulse is 78, temperature is 97.5, blood pressure is 132/74. Lungs are clear. He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. Abdomen is soft, nontender. No incisions. No umbilical hernia, no groin hernia, has a large abdominal pannus. No hepatosplenomegaly. Lower extremities; no pedal edema. No calf tenderness. Deep tendon reflexes are normal. Lungs are clear. S1, S2 is heard. Regular rate and rhythm. ,DISCUSSION:, I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient. The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. He will be seen by cardiologist, pulmonologist. He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox. He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. All these were discussed with the patient. The patient understands. He wants to go to surgery. All questions were answered. I will see him in few weeks before the planned date of surgery." }

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

{ "text_length": 4234 }

{ "text": "INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:, Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72. Blood pressure decreased from 160/84 to 130/78. The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test. 53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images are normal. The post Persantine images show mildly decreased uptake in the septum. The sum score is 0.,2. The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1. Mild septal ischemia. Likely due to the left bundle-branch block.,2. Mild cardiomyopathy, EF of 52%.,3. Mild hypertension at 160/84.,4. Left bundle-branch block.," }

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

{ "text_length": 1169 }

{ "text": "SUBJECTIVE: , I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day. The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.," }

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

{ "text_length": 1127 }

{ "text": "PROCEDURES:, Cystourethroscopy and transurethral resection of prostate.,COMPLICATIONS:, None.,ADMITTING DIAGNOSIS:, Difficulty voiding.,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lungs. Abdomen was negative for abnormal findings. ,LABORATORY DATA:, BUN 19 and creatinine 1.1. Blood group was A, Rh positive, Hemoglobin 13, Hematocrit 32.1, Prothrombin time 12.6 seconds, PTT 37.1. Discharge hemoglobin 11.4, and hematocrit 33.3. Chest x-ray calcified old granulomatous disease, otherwise normal. EKG was normal. ,COURSE IN THE HOSPITAL:, The patient had a cysto and TUR of the prostate. Postoperative course was uncomplicated. The pathology report is pending at the time of dictation. He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one a day for ten days with a standard postprostatic surgery instruction sheet. ,DISCHARGE DIAGNOSIS: , Enlarged prostate with benign bladder neck obstruction. ,To be followed in my office in one week and by Dr. ABC next available as an outpatient." }

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

{ "text_length": 1197 }

{ "text": "PREOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA: ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION: ,In the right flank-up position, table was flexed. He had a Foley catheter in place. Incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. The vena cava was identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down. The edges were freshened up. Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well. All sponge and instrument counts were correct. Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition." }

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

{ "text_length": 2241 }

{ "text": "SUBJECTIVE:, The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.,PAST MEDICAL HISTORY:, She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition.,MEDICATION:, Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs: Blood pressure is 124/72. Temperature 99.2. Respirations 20 unlabored. Weight: 137 pounds.,HEENT: Normocephalic. Conjunctivae noninjected. No mattering noted. Her TMs are bilaterally clear, nonerythematous. Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck: Supple. Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory: Clear. No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular: Regular rate and rhythm. S1 and S2 normal, no murmur.,Abdomen: Soft. No organomegaly. She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable. She has no suprapubic tenderness.,Extremities: She has good range of motion of upper and lower extremities. Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria. Culture and sensitivity is pending. Her Strep test is negative. Culture is pending.,ASSESSMENT:,1. Urinary dysuria.,2. Left flank pain.,3. Pharyngitis.,PLAN:, A 1 g of Rocephin IM was given. Call Dr. B's office tomorrow morning incase a second IM dose is needed. If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug. Push fluids. Await strep culture report. Follow up with Dr. XYZ if no better or symptoms worsen." }

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

{ "text_length": 2482 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left direct and indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia with Prolene mesh.,ANESTHESIA: , IV sedation with local.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to Recovery in stable condition.,SPECIMEN: , Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,BRIEF HISTORY: ,This is a 53-year-old male who presented to Dr. Y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh.,INTRAOPERATIVE FINDINGS: , The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac. The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,PROCEDURE: , After informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion. The left inguinal ligament was identified from the pubic tubercle to the ASIS. Two fingerbreadths above the pubic tubercle, a transverse incision was made. First, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length. Dissection was then carried down with electro Bovie cautery through Scarpa's fascia maintaining hemostasis. Once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel. Metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring. Next, the external oblique was grasped with Ochsner on both sides. The cord, cord structures as well as hernia sac were freed up circumferentially and a Penrose drain was placed around it. Next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats. A Metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored. There was some turbid fluid within the hernia sac, which was sent down for cultures. Gram stain was negative for organisms. Next, the hernia sac was to be ligated at its base and transected. A peon was used at the base. Metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen. An #0 Vicryl stick suture was used with #0 Vicryl loop suture to suture ligate the hernia sac at its base.,Next, attention was made to placing a Prolene mesh to cover the floor. The mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures. Attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact. Attention was next made after suturing the mesh with the #2-0 Polydek suture. The external oblique was then closed over the roof with a running #0 Vicryl suture, taking care not to strangulate the cord and to recreate the external ring. After injecting the external oblique and cord structures with Marcaine for anesthetic, the Scarpa's fascia was approximated with interrupted #3-0 Vicryl sutures. The skin was closed with a running subcuticular #4-0 undyed Vicryl suture. Steri-Strip with sterile dressings were applied.,The patient tolerated the procedure well and was transferred to Recovery in stable condition." }

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

{ "text_length": 3855 }

{ "text": "HISTORY: ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch. As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries. He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital. This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve. A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve. The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung. The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case. The patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries. This catheter was exchanged over wire. A 5-French marker pigtail catheter was directed into the main pulmonary artery. A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle. Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents. The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm. The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter. The left femoral venous sheath was exchanged over wire for a 7-French sheath. Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist. The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram. The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: ,Oxygen consumption was assumed to be in normal. Mixed venous saturation that was not normal with no evidence of intracardiac shunt. Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg. Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure. Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery. There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery. Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg. Left ventricular systolic pressure was systemic. No outflow constriction to the ascending aorta. Phasic ascending and descending pressures were similar and normal. The calculated systemic and pulmonary flows were equal and normal. Vascular resistances were normal. Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification. The proximal narrowing of the distal main pulmonary artery was appreciated. Neointimal ingrowth within the proximal stents were appreciated. There is good distal growth of the pulmonary arteries. Arborization appeared normal. Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch. Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation. Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%. The main pulmonary pressures remained similar. There was 10 mmHg systolic gradient into the branch of pulmonary arteries. There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg. Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve. A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens. There was no evidence of intimal disruption.,DIAGNOSES: ,1. Atrioventricular septal defect.,2. Tetralogy of Fallot with the pulmonary atresia.,3. Bilateral superior vena cava. The left cava draining to the coronary sinus.,4. The right aortic arch.,5. Discontinuous pulmonary arteries.,6. Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Repair of tetralogy of Fallot with external conduit.,3. The atrioventricular septal defect repair.,4. Unifocalization of branch pulmonary arteries.,5. Bilateral balloon pulmonary angioplasty and stent implantation.,6. Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES: ,1. Mild-to-moderate proximal branch pulmonary stenosis.,2. Well-functioning Contegra valve and current intervention. A balloon dilation of the right pulmonary artery.,3. Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued. Further cardiologic care be directed by Dr. X." }

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

{ "text_length": 7760 }

{ "text": "INDICATIONS: , The patient is a 22-year-old female with past medical history of syncope. The patient is also complaining of dizziness. She was referred here by Dr. X for tilt table.,TECHNIQUE: , Risks and benefits explained to the patient. Consent obtained. She was lying down on her back for 20 minutes and her blood pressure was 111/75 and heart rate 89. She was standing up on the tilt tablet for 20 minutes and her heart rate went up to 127 and blood pressure was still in 120/80. Then, the patient received sublingual nitroglycerin 0.4 mg. The patient felt dizzy at that time and heart rate was in the 120 and blood pressure was 110/50. The patient felt nauseous and felt hot at that time. She did not pass out.,COMPLICATIONS:, None.,Tilt table was then terminated.,SUMMARY:, Positive tilt table for vasovagal syncope with significant increase of heart rate with minimal decrease of blood pressure.,RECOMMENDATIONS: , I recommend followup in the office in one week and she will need Toprol-XL 12.5 mg every day if symptoms persist." }

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

{ "text_length": 1047 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS:, Nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES:, Kelman phacoemulsification with posterior chamber intraocular lens, right eye.,ANESTHESIA:, Topical.,COMPLICATIONS:, None.,INDICATION: , This is a 40-year-old male, who has been noticing problems with blurry vision. They were found to have a visually significant cataract. The risks, benefits, and alternatives of cataract surgery to the right eye were discussed and they did agree to proceed.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the operating room. A drop of tetracaine was instilled in the right eye and the right eye was prepped and draped in the usual sterile ophthalmic fashion. A paracentesis was created at ** o'clock. The anterior chamber was filled with Viscoat. A clear corneal incision was made at ** o'clock with the 3-mm diamond blade. A continuous curvilinear capsulorrhexis was begun with a cystotome and completed with Utrata forceps. The lens was hydrodissected with a syringe filled with 2% Xylocaine and found to rotate freely within the capsular bag. The nucleus was removed with the phacoemulsification handpiece in a stop and chop fashion. The residual cortex was removed with the irrigation/aspiration handpiece. The capsular bag was filled with Provisc and a model SI40, 15.0 diopter, posterior chamber intraocular lens was inserted into the capsular bag without complications and was found to rotate and center well. The residual Provisc was removed with the irrigation/aspiration handpiece. The wounds were hydrated and the eye was filled to suitable intraocular pressure with balanced salt solution. The wounds were found to be free from leak. Zymar and Pred Forte were instilled postoperatively. The eye was covered with the shield.,The patient tolerated the procedure well and there were no complications. He will follow up with us in one day." }

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

{ "text_length": 2000 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,POSTOPERATIVE DIAGNOSIS: , Coronary occlusive disease.,OPERATION PROCEDURE: , Coronary bypass graft x2 utilizing left internal mammary artery, the left anterior descending, reverse autogenous reverse autogenous saphenous vein graft to the obtuse marginal. Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,INDICATION FOR THE PROCEDURE: ,The patient was a 71-year-old female transferred from an outside facility with the left main, proximal left anterior descending, and proximal circumflex severe coronary occlusive disease, ejection fraction about 40%.,FINDINGS: , The LAD was 2-mm vessel and good, mammary was good, and obtuse marginal was 2-mm vessel and good, and the main was good.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring devices were placed. The chest, abdomen and legs were prepped and draped in the sterile fashion. The right greater saphenous vein was harvested and prepared by 2 interrupted skin incisions and by ligating all branches with 4-0 Surgilon and flushed with heparinized blood. Hemostasis was achieved in the legs and closed with running 2-0 Dexon in the subcutaneous tissue and running 3-0 Dexon subcuticular in the skin.,Median sternotomy incision was made and the left mammary artery was dissected free from its takeoff of the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The pericardium was opened. The pericardial cradle was created. The patient was fully heparinized and cannulated with a single aortic and single venous cannula and bypass was instituted. A retrograde cardioplegic cannula was placed with a pursestring suture of 4-0 Prolene suture in the right atrial wall into the coronary sinus and tied to a Rumel tourniquet. An antegrade cardioplegic needle sump combination was placed in the ascending aorta and tied in place with 4-0 Prolene. Cardiopulmonary bypass was instituted and the ascending aorta was crossclamped. Antegrade cardioplegia was given at a total of 5 mL per kg through the aortic route. This was followed by something in the aortic route and retrograde cardioplegia through the coronary sinus at a total of 5 mL per kg. The obtuse marginal coronary was identified and opened.,End-to-side anastomosis was performed with a running 7-0 Prolene suture and the vein was cut to length. Cold antegrade and retrograde potassium cardioplegia were given. The mammary artery was clipped distally, divided and spatulated for anastomosis. The anterior descending was identified and opened. End-to-side anastomosis was performed with running 8-0 Prolene suture and the warm blood potassium cardioplegia was given antegrade and retrograde and the aortic cross-clamp was removed. The partial occlusion clamp was placed. Aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. A partial occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Ventilation was commenced. The patient was fully warm and the patient was then wean from cardiopulmonary bypass. The patient was decannulated in routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire plus two 5-mm Mersiline tapes.,The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch. The patient tolerated the procedure well." }

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

{ "text_length": 3830 }

{ "text": "Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed." }

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

{ "text_length": 5781 }

{ "text": "TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch. She has now been put forward for operative intervention.,PREOP DIAGNOSIS: ,1. Patent ductus arteriosus.,2. Severe prematurity.,3. Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation. After completion of the procedure, left recurrent laryngeal nerve visualized and preserved. Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced. The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed. Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma. The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus. The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion. It was then test occluded and then interrupted with a medium titanium clip. There was preserved pulsatile flow in the descending aorta. The left recurrent laryngeal nerve was identified and preserved. With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers. The skin was closed with a running 6-0 Caprosyn suture. A sterile dressing was placed. Sponge and needle counts were correct times 2 at the end of the procedure. The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case." }

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

{ "text_length": 2282 }

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

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

{ "text_length": 5116 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Varicose veins.,POSTOPERATIVE DIAGNOSIS: , Varicose veins.,PROCEDURE PERFORMED:,1. Ligation and stripping of left greater saphenous vein to the level of the knee.,2. Stripping of multiple left lower extremity varicose veins.,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 150 mL.,SPECIMENS: , Multiple veins.,COMPLICATIONS:, None.,BRIEF HISTORY:, This is a 30-year-old Caucasian male who presented for elective evaluation from Dr. X's office for evaluation of intractable pain from the left lower extremity. The patient has had painful varicose veins for number of years. He has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins. It was recommended that the patient undergo a saphenous vein ligation and stripping. He was explained the risks, benefits, and complications of the procedure including intractable pain. He gave informed consent to proceed.,OPERATIVE FINDINGS:, The left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,The vein was stripped from the saphenofemoral junction to the level of the knee. Multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly. Additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,OPERATIVE PROCEDURE: ,The patient was marked preoperatively in the Preanesthesia Care Unit. The patient was brought to the operating suite, placed in the supine position. The patient underwent general endotracheal intubation. After adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline. A diagonal incision was created in the direction of the inguinal crease on the left. A self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified. The vein was isolated with a right angle. The vein was followed proximally until a multiple tributary branches were identified. These were ligated with #3-0 silk suture. The dissection was then carried to the femorosaphenous vein junction. This was identified and #0 silk suture was placed proximally and distally and ligated in between. The proximal suture was tied down. Distal suture was retracted and a vein stripping device was placed within the greater saphenous vein. An incision was created at the level of the knee. The distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated. The distal end of the vein stripping device was then passed through at its most proximal location. The device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity. Next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg. Multiple incisions were created with a #15 blade scalpel. The incisions were carried down with electrocautery. Next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified. The vein was then followed to T3 and in all these locations intersecting segments of varicose veins were identified and removed. Additionally, some segments were removed. The stripping approach would be vein stripping device. Multiple branches of the saphenous vein were then ligated and/or removed. Occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat. Bleeding was controlled with direct pressure. All incisions were then closed with interrupted #3-0 Vicryl sutures and/or #4-0 Vicryl sutures.,The femoral incision was closed with interrupted multiple #3-0 Vicryl sutures and closed with a running #4-0 subcuticular suture. The leg was then cleaned, dried, and then Steri-Strips were placed over the incisions. The leg was then wrapped with a sterile Kerlix. Once the Kerlix was achieved, an Ace wrap was placed over the left lower extremity for compression. The patient tolerated the procedure well and was transferred to Postanesthesia Care Unit extubated in stable condition. He will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit." }

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

{ "text_length": 4681 }

{ "text": "ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise. He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Tympanic membranes were red and yellow, and opaque bilaterally. Nares were patent. Oropharynx was slightly moist and pink. Neck was soft and supple without masses. Heart is regular rate and rhythm without murmurs. Lungs showed increased workup of breathing, moderate tachypnea. No rales, rhonchi or wheezes were noted. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Neurologic exam showed good muscle strength, normal tone. Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits. White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. Urinalysis was completely unremarkable. Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet. Activity is as tolerates. CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered. Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%. Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration. He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers. Overnight, he did have his oxygen saturations drop and went into oxygen overnight. His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. The nurses were instructed to attempt to wean O2 if possible and advance the diet. He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient. He did well the following evening with no further oxygen requirement. He continued to spike fevers but last fever was around 13:45 on the previous day. At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs. He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night. He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1. Bilateral otitis media.,2. Fever.,PLAN: ,Recommended discharge. No restrictions in diet or activity. He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday. Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy." }

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

{ "text_length": 3925 }

{ "text": "IDENTIFYING DATA:, The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:, The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:, The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D. Historically, he has found it very easy to be distracted in the \"cubicle\" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is \"better now,\" but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:, The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon." }

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

{ "text_length": 2210 }

{ "text": "ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise. He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Tympanic membranes were red and yellow, and opaque bilaterally. Nares were patent. Oropharynx was slightly moist and pink. Neck was soft and supple without masses. Heart is regular rate and rhythm without murmurs. Lungs showed increased workup of breathing, moderate tachypnea. No rales, rhonchi or wheezes were noted. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Neurologic exam showed good muscle strength, normal tone. Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits. White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. Urinalysis was completely unremarkable. Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet. Activity is as tolerates. CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered. Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%. Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration. He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers. Overnight, he did have his oxygen saturations drop and went into oxygen overnight. His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. The nurses were instructed to attempt to wean O2 if possible and advance the diet. He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient. He did well the following evening with no further oxygen requirement. He continued to spike fevers but last fever was around 13:45 on the previous day. At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs. He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night. He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1. Bilateral otitis media.,2. Fever.,PLAN: ,Recommended discharge. No restrictions in diet or activity. He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday. Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy." }

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

{ "text_length": 3925 }

{ "text": "SUBJECTIVE:, This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome. The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it. She is not sure that she was following it accurately. She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well. Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off. However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:, Weight is 275 pounds. Food records were reviewed.,ASSESSMENT:, The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago. I did carefully review her food records and evaluated calories consumed. While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected. Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well. She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates. While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction. We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:, A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat. This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack. This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack. We have eliminated the morning snack. The patient will now track the grams of fat in her meats as well as added fats. Her goal for total fats over the course of the day is no more than 42 grams of fat per day. This was a half hour consultation. We will plan to see the patient back in one month for support." }

[ { "label": " Diets and Nutritions", "score": 1 } ]

{ "text_length": 2533 }

{ "text": "DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1." }

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

{ "text_length": 123 }

{ "text": "CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, which she feels to have helped. The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. At that time, the patient also had significant increasing congestion. Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated. A chest x-ray was obtained and was noted to be normal. The patient's saturations were noted to be normal and the patient was discharged home. Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. The patient had a 101 temperature on Wednesday evening, but has had no true fevers. The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: ,As above.,IMMUNIZATIONS:, None.,PAST MEDICAL HISTORY: ,No hospitalizations. No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery. Birth weight 6 pounds 12 ounces. Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma. Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother. There is one bird. There are smokers in the household. There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress.,HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.,NECK: Supple. No lymphadenopathy.,CHEST: Exhibits symmetric expansion and retractions.,LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.,GU: Normal female. No discharge or erythema.,BACK: Normal with a normal curvature.,EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. A urinalysis obtained in the emergency room was noted to be negative. CRP was noted to be 2.0. The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis. At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Currently, at this time, I feel no respiratory treatments are indicated in this patient. I hear no evidence of wheezing or reactive airway disease. We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness." }

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

{ "text_length": 5005 }

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

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

{ "text_length": 3001 }

{ "text": "CHIEF COMPLAINT:, Not gaining weight.,HISTORY OF PRESENT ILLNESS:, The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds. The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur. At this point, the Hospitalist Service was contacted for admission. The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure. The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female. Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking. Birthweight was 7 pounds 4 ounces at Community Hospital. The mother did have a repeat C-section. There is no rupture of membranes or group B strep status. The prenatal care began in the second month of pregnancy and was otherwise uncomplicated. Mother denies any sexual transmitted diseases or other significant illness. The patient was discharged home on day of life #3 without any complications.,ALLERGIES:, No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother. She has 2 older male siblings. All were reported good health. Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS: ,GENERAL: The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain. Mother does not report that she sweats whenever she eats or has any episodes of cyanosis. ,HEENT: Denies any significant nasal congestion or cough. ,RESPIRATORY: Denies any difficulty breathing or wheezing. ,CARDIOVASCULAR: As per above. GI: No history of any persistent vomiting or diarrhea. ,GU: Denies any decreased urinary output. ,MUSCULOSKELETAL: Negative. ,NEUROLOGICAL: Negative. ,SKIN: Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is examined in her room, our next floor. She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS: Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT: Normocephalic. The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head. The anterior fontanelle is soft and flat. Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism. There is also some mild posterior rotation of the ears. Oropharynx, mucous membranes are pink and moist. There is a slightly high arched palate.,NECK: Significant for possible mild reddening of the neck.,LUNGS: Significant for perihilar crackles. Mild tachypnea is noted. O2 saturations are currently 97% on room air. There is mild intercostal retraction.,CARDIOVASCULAR: Heart has regular rate and rhythm. Peripheral pulses are only 1+. Capillary refills less than 3-4 seconds.,EXTREMITIES: Slightly cool to touch. There is 2-3/6 systolic murmur along the left sternal border. Does radiate to the axilla and to the back.,ABDOMEN: Soft, slightly distended, but nontender. The liver edge is palpable 4 cm below right costal margin. The spleen tip is also palpable.,GU: Normal female external genitalia is noted.,MUSCULOSKELETAL: The patient has poor fat deposits in her extremities. Strength is only 2/4. She had normal number of fingers and toes.,SKIN: Significant for slight mottling. There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4. CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4. Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1. Failure-to-thrive.,2. Significant murmur and patent ductus arteriosus.,3. Congestive heart failure.,PLAN: ,At present, we are going to admit and monitor closely tonight. We will get a chest x-ray and start Lasix at 1 mg/kg twice daily. We will also get a CBC and check a blood culture and further workup as necessary." }

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

{ "text_length": 5267 }

{ "text": "CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 45-year-old white male who was admitted with acute back pain. The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years. On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright. He was seen at ABCD Hospital Emergency Room, was evaluated and admitted. He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A. It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007. He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes. The patient reports that he has had a \" bulging disk\" for approximately 1 year. He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative. The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:, Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department. He is a nonsmoker. He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends. He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors. Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis. The patient reports that his last bowel movement was on 08/30/2007. No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties. The patient does report that he has occasional intermittent \"numbness and tingling\" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome. He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS: At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air. The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL: The patient appears to be comfortable, in no acute distress.,HEENT: Normocephalic. Sclerae are nonicteric. EOMI. Tongue is at midline and no evidence of thrush.,NECK: Trachea is at the midline.,LYMPHATICS: No cervical or axillary nodes palpable.,LUNGS: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Obese, softly protuberant, and nontender.,EXTREMITIES: There is no clubbing, cyanosis or edema. There is no calf tenderness bilaterally. Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity. The right lower extremity is 4-5/5.,MENTAL STATUS: He is alert and oriented. He was pleasant and cooperative during the examination.,ASSESSMENT:,1. Acute on chronic back pain. The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy. He will be seen in consultation by Physical Therapy and Occupational Therapy. He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2. Status post right orchiectomy secondary to testicular cancer, stable at this time. We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3. Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis. Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4. Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5. Obesity. As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested." }

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

{ "text_length": 5023 }

{ "text": "FINDINGS:,There is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent CSF within the subarachnoid spaces. There is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. There is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. There is a cavum velum interpositum (normal variant).,There is a linear area of T1 hypointensity becoming hyperintense on T2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,Normal basal ganglia and thalami. Normal internal and external capsules. Normal midbrain.,There is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. There are areas of T2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. The area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. Interval reassessment of this lesion is recommended.,There is a remote lacunar infarction of the right cerebellar hemisphere. Normal left cerebellar hemisphere and vermis.,There is increased CSF within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. There is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,Normal flow within the carotid arteries and circle of Willis.,Normal calvarium, central skull base and temporal bones. There is no demonstrated calvarium metastases.,IMPRESSION:,Severe generalized cerebral atrophy.,Extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. The area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. Interval reassessment of this lesion is recommended.,Remote lacunar infarction in the right cerebellar hemisphere.,Linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,No demonstrated calvarial metastases." }

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

{ "text_length": 2620 }

{ "text": "PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication. She had severe dyspareunia and chronic suprapelvic pain. The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process. Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain. She desired surgical treatment. She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs. The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa. Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon. Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind. Ureter visualized and palpated on right and appears normal. Indigo carmine given IV with no leaks intraperitoneally noted. Sigmoid colon dissected free from back of uterus and from cul-de-sac. Bowel free of lacerations or denudation. Upon inspection, right tube with hydrosalpinx, appendix absent. Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia. She was placed in a supine position with a transurethral Foley in place and compression stockings in place. The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum. The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs. Next, exploration of the abdominal and pelvic organs revealed the above noted findings. The uterus was enlarged and probably contained adenomyosis. There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within. The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus. A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges. Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel. Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb. The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder. The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted. Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed. The right round ligament was suture-ligated with 0 Polysorb. It was transected and divided with electrocautery. The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular. The left infundibulopelvic ligament was identified. It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted. Next, the uterine arteries were skeletonized on the right. They were transected and suture-ligated with 0 Polysorb. The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb. The cardinal ligaments were taken near their insertion into the cervical and uterine tissue. Pedicles were sharply developed and suture-ligated with 0 Polysorb. Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina. Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors. The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support. The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon. It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind. The right ureter was seen and palpated. It did not appear to be dilated and had good peristalsis noted. Next, the retractors were removed. The laparotomy sponges were removed from the abdomen. The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline. The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion. The skin was closed with 4-0 Polysorb in a subcuticular fashion. A thin layer of Dermabond was placed.,The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x 2. Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:, None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.," }

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

{ "text_length": 5947 }

{ "text": "PREOPERATIVE DIAGNOSES:, Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:, Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped. He was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. He did receive antibiotics post procedure. He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. Burr hole was drilled with the cranial twist drill. The dura was punctured with a twist drill. A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless. The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal. None replaced." }

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

{ "text_length": 1523 }

{ "text": "SUBJECTIVE:, This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.,OBJECTIVE:, Her reported height is 5 feet 4 inches. Today’s weight was 170 pounds. BMI is approximately 29. A diet history was obtained. I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well. Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:, The patient’s basal energy expenditure is estimated at 1361 calories a day. Her total calorie requirement for weight maintenance is estimated at 1759 calories a day. Her diet history reflects that she is making some very healthy food choices on a regular basis. She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals. She also is emphasizing lower fat selections. Her physical activity level is moderate at this time. She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend. We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction. We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well. We discussed menu selection, as well as food preparation techniques. The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that. I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:, Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk. Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week. This translates into a 1200-calorie meal plan. I encouraged the patient to keep food records in order to better track calories consumed. I recommended low fat selections and especially those that are lower in saturated fats. Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well. This was a one-hour consultation. I provided my name and number should additional needs arise." }

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

{ "text_length": 3072 }

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

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

{ "text_length": 4296 }

{ "text": "PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was normal. The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors. There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair. There was no sign of reflux esophagitis. On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body. It had 2 to 3 mm diameter. This was broken up using a scope into smaller pieces. There was no retained gastric liquid. The antrum appeared normal and the pylorus was patent. The scope passed easily into the duodenum, which was normal through the second portion. On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing. The scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal postoperative hernia repair.,2. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3. Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1. Continue proton pump inhibitors.,2. Use Reglan 10 mg three to four times a day." }

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

{ "text_length": 1556 }

{ "text": "HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicuspid aortic valve was also seen without insufficiency or stenosis. The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE: ,After sedation and general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place. There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle. A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery. The transverse arch measured 5 mm. Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level. The diaphragm measured 5.6 mm. The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery. This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist. Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient. Repeat angiogram showed mild improvement in degree of aortic narrowing. The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist. The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the pediatric intensive care unit in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to mild systemic arterial desaturation and anemia. There is no evidence of significant intracardiac shunt. Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg. Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta. The calculated flows were mildly increased. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels. There is discrete juxtaductal coarctation of the aorta. Flow within the intercostal arteries was retrograde. Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg. There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta. The calculated systemic flow fell to normal values. Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus. There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries. The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES: ,1. Juxtaductal coarctation of the aorta.,2. Dilated cardiomyopathy.,3. Bicuspid aortic valve.,4. Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference. The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery. The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months. The further cardiologic care will be directed by Dr. X." }

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

{ "text_length": 5404 }

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

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

{ "text_length": 1016 }

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

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

{ "text_length": 620 }

{ "text": "CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, which she feels to have helped. The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. At that time, the patient also had significant increasing congestion. Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated. A chest x-ray was obtained and was noted to be normal. The patient's saturations were noted to be normal and the patient was discharged home. Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. The patient had a 101 temperature on Wednesday evening, but has had no true fevers. The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: ,As above.,IMMUNIZATIONS:, None.,PAST MEDICAL HISTORY: ,No hospitalizations. No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery. Birth weight 6 pounds 12 ounces. Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma. Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother. There is one bird. There are smokers in the household. There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress.,HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.,NECK: Supple. No lymphadenopathy.,CHEST: Exhibits symmetric expansion and retractions.,LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.,GU: Normal female. No discharge or erythema.,BACK: Normal with a normal curvature.,EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. A urinalysis obtained in the emergency room was noted to be negative. CRP was noted to be 2.0. The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis. At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Currently, at this time, I feel no respiratory treatments are indicated in this patient. I hear no evidence of wheezing or reactive airway disease. We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness." }

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

{ "text_length": 5005 }

{ "text": "REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization. He has also been seen by me in the clinic in the last few weeks. He was admitted on January 18, 2008, with recurrent malignant pleural effusion. On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X. He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma. His hospital course here has been significant for dyspnea, requiring ICU stay. He also had a chest tube, which was taken out few days ago. He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist. The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma. Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31. Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days. He does have edema in his lower extremities. He is currently on 4L of oxygen. He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia. No neurological or musculoskeletal signs or symptoms. He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion. He denies any other complaints.,PAST MEDICAL HISTORY:, Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital. History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS: ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse. He has history of tobacco smoking and also reports history of alcohol abuse. No history of illicit drug abuse.,FAMILY HISTORY: ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above. He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL: He is awake, alert, in no acute distress. He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS: Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT: No icterus or sinus tenderness. Oral mucosa is moist.,NECK: Supple. No lymphadenopathy.,LUNGS: Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR: S1 and S2 normal.,ABDOMEN: Soft, nondistended, and nontender. No hepatosplenomegaly. Bowel sounds are present in all four quadrants.,EXTREMITIES: Bilateral pedal edema is present in both the extremities. No signs of DVT.,NEUROLOGICAL: Grossly nonfocal.,INVESTIGATION:, Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9. Liver enzymes checked on January 17, 2008, were unremarkable. CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000. Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1. Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2. Chronic obstructive pulmonary disease.,3. Paroxysmal atrial fibrillation.,4. Malignant pleural effusion, status post surgery as stated above.,5. Anemia of chronic disease.,RECOMMENDATIONS,1. Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides. I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital. I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2. I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3. Once the results of the above are available, I will make further recommendations regarding treatment. The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4. Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction. They clearly understand the above. They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this." }

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

{ "text_length": 5243 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion. The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg. I made a transverse incision directly over the ganglion. Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them. I then excised the ganglion and its stalk. In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve. We then identified the scapholunate ligament, which was uninjured. I irrigated and closed in layers and injected Marcaine with epinephrine. I dressed and splinted the wound. The patient was sent to the recovery room in good condition, having tolerated the procedure well." }

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

{ "text_length": 1057 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:, Spinal.,PROCEDURE IN DETAIL:, The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic. The right inguinal region was shaved and prepped and draped in a routine sterile fashion. The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue. The external oblique fascia was exposed and incised down to and through the external inguinal ring. The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal. The cord was surrounded with a Penrose drain. The hernia sac was separated from the cord structures. The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene. Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord. It was placed around the cord and sutured to itself with 2-0 Prolene. The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene. The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief. The cord was returned to its position. External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips. Sponge and needle counts were correct. Sterile dressing was applied." }

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

{ "text_length": 1848 }

{ "text": "PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops. A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg. The eye was prepped with a Betadine solution and draped in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition." }

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

{ "text_length": 2413 }

{ "text": "EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home." }

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

{ "text_length": 2408 }

{ "text": "REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.,REVIEW OF SYSTEMS: ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs: Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General: She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT: Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.,Neck: Trachea appeared to be in the midline.,Chest: Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular: Showed a normal sinus rhythm without murmur.,Abdomen: Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities: Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.,Neurological: From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:, A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1. For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2. As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3. I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.,4. The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then." }

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

{ "text_length": 4860 }

{ "text": "REASON FOR VISIT:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above." }

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

{ "text_length": 4415 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mmHg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate. The Agee Inside Job was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision. After complete division of transverse carpal ligament, the Agee Inside Job was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished. One cc of Celestone was then introduced into the carpal tunnel and irrigated free. ,The wound was then closed with a running 3-0 Prolene subcuticular stitch. Steri-strips were applied and a sterile dressing was applied over the Steri-strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well." }

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

{ "text_length": 2316 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:, Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:, General LMA.,TOURNIQUET TIME: ,9 minutes at 200 torr.,FINDINGS:, The patient was found to have limitations to extension at the IP joint to the right thumb. He was found to have full extension after release of A1 pulley.,INDICATIONS:, The patient is 2-1/2-year-old. He has a history of a trigger thumb. This was evaluated in the office. He was indicated for release of A1 pulley to allow for full excursion. Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family. They wanted to proceed.,PROCEDURE:, The patient was brought into the operating room and placed on the operating table in supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. The right upper extremity was then prepped and draped in a standard fashion. Limb was exsanguinated with an Esmarch bandage. Tourniquet was raised to 200 torr. Transverse incision was then made at the base of thumb. The underlying soft tissues were carefully spread in line longitudinally. The underlying tendon was then identified. The accompanied A1 pulley was also identified. This was incised longitudinally using #11 blade. Inspection of the entire tendon then demonstrated good motion both in flexion and extension. The leaflets of the pulley were easily identified.,The wound was then irrigated and closed. The skin was closed using interrupted #4-0 Monocryl simple sutures. The area was injected with 5 mL of 0.25% Marcaine. The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban. The patient was awakened from anesthesia and taken to the recovery room in good condition. There were no complications. All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home. He will return in 1-1/2 weeks for wound inspection." }

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

{ "text_length": 2070 }

{ "text": "GENERAL REVIEW OF SYSTEMS,General: No fevers, chills, or sweats. No weight loss or weight gain.,Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations.,Neurologic: No paresis, paresthesias, or syncope.,Eyes: No double vision or blurred vision.,Ears: No tinnitus or decreased auditory acuity.,ENT: No allergy symptoms, such as rhinorrhea or sneezing.,GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits.,GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream.,Psych: No symptoms of depression or anxiety.,Pulmonary: No wheezing, cough, or sputum production.,Skin: No skin lesions or nonhealing lesions.,Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints.,Endocrine: No heat or cold intolerance. No polydipsia.,Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.,PHYSICAL EXAM,Vitals: Blood pressure today was *, heart rate *, respiratory rate *.,Ears: TMs intact bilaterally. Throat is clear without hyperemia.,Mouth: Mucous membranes normal. Tongue normal.,Neck: Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest: Clear to auscultation; no dullness to percussion.,Heart: Revealed a regular rhythm, normal S1 and S2. No murmurs, clicks or gallops.,Abdomen: Soft to palpation without guarding or rebound. No masses or hepatosplenomegaly palpable. Bowel sounds are normoactive.,Extremities: Bilaterally symmetrical. Peripheral pulses 2+ in all extremities. No pedal edema.,Neurologic examination: Essentially intact including cranial nerves II through XII intact bilaterally. Deep tendon reflexes 2+ and symmetrical.,Breasts: Bilaterally symmetrical without tenderness, masses. No axillary tenderness or masses.,Pelvic examination: Revealed normal external genitalia. Pap smear obtained without difficulty. Bimanual examination revealed no pelvic tenderness or masses. No uterine enlargement. Rectal examination revealed normal sphincter tone, no rectal masses. Stool is Hemoccult negative." }

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

{ "text_length": 2154 }

{ "text": "NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented. There is no evidence of cognitive or language dysfunction. Cranial nerves: Visual fields are full. Funduscopic examination is normal. Extraocular movements full. Pupils equal, round, react to light. There is no evidence of nystagmus noted. Fifth nerve function is normal. There is no facial asymmetry noted. Lower cranial nerves are normal. ,Manual motor testing reveals good tone and bulk throughout. There is no evidence of pronator drift or decreased fine finger movements. Muscle strength is 5/5 throughout. Deep tendon reflexes are 2+ throughout with downgoing toes. Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk. Finger-to-nose and heel-to-shin moves are normal. Romberg sign negative. I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection." }

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

{ "text_length": 1081 }

{ "text": "SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.,CURRENT MEDICATIONS:, The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:, Erythromycin.,REVIEW OF SYSTEMS:, Significant for problems with agitated depression. Her respiratory status is unchanged as noted above.,EXAMINATION:,General: The patient is in no acute distress.,Vital signs: Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular: Distant heart tones. Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1. Chronic obstructive pulmonary disease/emphysema, severe but stable.,2. Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. History of depression and schizophrenia.,PLAN:, At this point, I have recommended that she continue current respiratory medicine. I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. I have recommended that she use it with activity and at night. I spoke with her about her living situation. Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be." }

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

{ "text_length": 2323 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct inguinal hernia.,PROCEDURE PERFORMED:, Rutkow direct inguinal herniorrhaphy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. Preoperative antibiotics were given for prophylaxis against surgical infection. The patient was prepped and draped in the usual sterile fashion.,A standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of Metzenbaum scissors and Bovie electrocautery. The external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated. The external oblique was then incised with a scalpel and this incision was carried out to the external ring using Metzenbaum scissors. Having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a Penrose drain was placed around the cord structures at the level of the pubic tubercle. This Penrose drain was then used to retract the cord structures as needed. Adherent cremasteric muscle was dissected free from the cord using Bovie electrocautery.,The cord was then explored using a combination of sharp and blunt dissection, and no sac was found. The hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels. This was dissected back to the hernia opening. The hernia was inverted back into the abdominal cavity and a large PerFix plug inserted into the ring. The plug was secured to the ring by interrupted 2-0 Prolene sutures.,The PerFix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 Prolene sutures. By reinforcing the floor with the onlay patch, a new internal ring was thus formed.,The Penrose drain was removed. The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery. The incision in the external oblique was approximated using a 2-0 Vicryl in a running fashion, thus reforming the external ring. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition." }

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

{ "text_length": 2587 }

{ "text": "CHIEF COMPLAINT AND IDENTIFICATION:, A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,HISTORY OF PRESENT ILLNESS: , The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.,She has no hospitalizations.,The patient has had a 1 week or so history of cough. She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom. She has been taking 1 teaspoon every 6 hours. She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis. She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.,At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,REVIEW OF SYSTEMS: , Negative except that indicated in the history of present illness. All systems were checked.,PAST MEDICAL HISTORY: , As stated in the history of present illness, no hospitalizations, no surgeries.,IMMUNIZATIONS: , The patient is up-to-date on her shots. She has a schedule for her 2-year-old shot soon.,ALLERGIES: , No known drug allergies.,DEVELOPMENT HISTORY: , Developmentally, she is within normal limits.,FAMILY HISTORY:, Her maternal uncles have asthma. There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,SOCIAL HISTORY: , Her sister has a runny nose, but no other sick contacts. The family lives in Delano. She lives with her mom and sister. The dad is involved, but the parents are separated. There is no smoking exposure.,PHYSICAL EXAMINATION:, ,GENERAL: The child was in no acute distress.,VITAL SIGNS: Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28. Oxygen saturations 98% on continuous. Off of oxygen shows 85% laying down on room air. The T-max in the ER was 101.3 degrees Fahrenheit.,SKIN: Clear.,HEENT: Pupils were equal, round, react to light. No conjunctival injection or discharge. Tympanic membranes were clear. No nasal discharge. Oropharynx moist and clear.,NECK: Supple without lymphadenopathy, thyromegaly, or masses.,CHEST: Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,CARDIOVASCULAR: Regular rate and rhythm. No murmurs noted. Well perfused peripherally.,ABDOMEN: Bowel sounds are present. The abdomen is soft. There is no hepatosplenomegaly, no masses, nontender to palpation.,GENITOURINARY: No inguinal lymphadenopathy. Tanner stage I female.,EXTREMITIES: Symmetric in length. No joint effusions. She moves all extremities well.,BACK: Straight. No spinous defects.,NEUROLOGIC: The patient has a normal neurologic exam. She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive. She has no focal neurologic deficits.,LABORATORY DATA: , Chest x-ray by my reading shows a right lower lobe infiltrate. Metabolic panel: Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3. White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000. Differential of the white count 34% lymphocytes, 55% neutrophils.,ASSESSMENT AND PLAN: , This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress. I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment. She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage. She is being admitted for hypoxemia. I hope that this will resolve overnight, and she will be discharged in the morning. I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,Further interventions will depend on the clinical course." }

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

{ "text_length": 4606 }

{ "text": "PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test. She was transfused with packed red blood cells. Her hemolysis seemed to slow down. She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. She had a blood culture, which was also negative. She was empirically started on presentation with the cefotaxime intravenously. Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. Questions were answered to their satisfaction. They would like to proceed.,PROCEDURE IN DETAIL: , After \"time out\" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. She was then given Versed 1 mg intravenously by myself. She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. She was then given 20 mcg of fentanyl intravenously by myself. She was placed in the left lateral decubitus position. Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution. She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision. Clear fluid was not obtained initially, needle was withdrawn intact. The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained. The stylette was replaced and the needle was withdrawn intact and bandage was applied. Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable. Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition." }

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

{ "text_length": 3252 }

{ "text": "IDENTIFYING DATA:, Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior. Recently, she was picked up by Kent Police Department \"leaping on Highway 99.\",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY: ,Unknown.,ALLERGIES:, Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:, Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit. General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2. Previous urine tox was positive for THC. Urinalysis was negative, but did note positive UA wbc's. CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I: Psychosis. Inpatient Psychiatric Team to follow.,AXIS II: Deferred.,AXIS III: We were unable to perform physical examination on the patient today secondary to her being in seclusion. Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI. We will wait until the patient is out of seclusion to perform examination. Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy. We will followup with the patient should any new medical issues arise." }

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

{ "text_length": 1808 }

{ "text": "EXAM: , Screening full-field digital mammogram.,HISTORY:, Screening examination of a 58-year-old female who currently denies complaints. Patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy. The patient's sister was also diagnosed with breast cancer at the age of 59.,TECHNIQUE: , Standard digital mammographic imaging was performed. The examination was performed with iCAD Second Look Version 7.2.,COMPARISON: , Most recently obtained __________.,FINDINGS: , The right breast is again smaller than the left. There is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast. The breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue. There is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes. A few benign-appearing microcalcifications are present.,No dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified. The skin is stable. No enlarged axillary lymph node is seen.,IMPRESSION:,1. No significant interval changes are seen. No mammographic evidence of malignancy is identified.,2. Annual screening mammography is recommended or sooner if clinical symptoms warrant.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized." }

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

{ "text_length": 1865 }

{ "text": "REASON:, Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS: ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank. She states that is particularly bad when up and walking around, goes away when she is lying down. She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm. She states that she feels a bit like she did when she had her gallbladder removed nine years ago. Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles. She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1. Hydrochlorothiazide 25 mg p.o. daily.,2. Lisinopril 10 mg p.o. daily.,3. Albuterol p.r.n.,PAST MEDICAL HISTORY: ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease. Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well. Father with coronary artery disease. She has siblings who have increased cholesterol.,SOCIAL HISTORY: ,The patient does not smoke. She quit 25 years ago. She drinks one beer a day. She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL: Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS: Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT: Normocephalic and atraumatic. Sclerae are without icterus. Conjunctivae are not injected.,NECK: Neck is supple. Carotids 2+. Trachea is midline. Carotids are without bruits.,LYMPH NODES: There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS: Clear to auscultation.,CARDIAC: Regular rate and rhythm.,ABDOMEN: Soft. No hepatosplenomegaly. She has a positive Rovsing sign and a positive obturator sign. She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES: Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses. She has only trace edema with varicosities around the bilateral ankles.,CNS: Without gross neurologic deficits.,INTEGUMENTARY: Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells. White blood cell count is 20,000 with 75 polys and 16 lymphs. H&H is 13.7 and 39.7. Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98. Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91. Lipase is 19. CAT scan is negative for acute appendicitis. In fact, it mentions that the appendix is not discretely identified. There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:, Plan is to admit the patient. Recheck the white blood cell count in the morning. Re-examine her and further plan is pending, the results of that evaluation." }

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

{ "text_length": 3392 }

{ "text": "XYZ, D.C.,Re: ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The patient sustained impact injuries to his neck and lower back. There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures. He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg. He has had no difficulty with bowel or bladder function. He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:, He was injured in a prior motor vehicle accident on MM/DD/YYYY. At the time of his most recent injuries, he was completely symptom free and under no active therapy. There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS: ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:, Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level. MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function. Vital Signs: Blood pressure was 105/68 in the left arm sitting. Heart rate was 70 and regular. Height was 5 feet 8 inches. Weight was 182 pounds. Cranial nerve evaluation was unremarkable. Pupils were equal and reactive. Funduscopic evaluation was clear. There was no evidence for nystagmus. There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature. Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ symmetrical and active. No pathological responses were noted. Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity. Cerebellar function was normal. There was normal station and gait. Chest and cardiovascular evaluations were unremarkable. Heart sounds were normal. There were no extra sounds or murmurs. Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY. In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms. Palpable trigger points were noted on today's evaluation. He is suffering from ongoing myofascitis. His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time. I have encouraged him to continue with his ongoing treatment program under your care and supervision. I will be following him in two weeks' time. Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,," }

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

{ "text_length": 4182 }

{ "text": "ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. This occurred at 2:30 a.m. His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. He underwent workup including a CT, which was negative and his symptoms slowly began to resolve. He was initially admitted, placed on Plavix and aspirin. However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted. He also underwent an echo, carotid ultrasound, and lab work in the emergency room. Wife is at the bedside and denies he had any other symptoms previous to this. He denied any chest pain or palpitations. She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES: ,He has no known drug allergies.,CURRENT MEDICATIONS:,1. Multivitamin.,2. Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1. Nasopharyngeal cancer. Occurred in 1991. Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. Lumbar disk disease.,3. Status post diskectomy.,4. Chronic neck pain secondary to XRT.,5. History of thalassemia.,6. Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.,FAMILY HISTORY: ,Pertinent for father who died of an inoperable brain tumour. Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS: ,He reports he was in his usual state of health up until he awoke this morning. He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS: Stable. His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL: He is alert, pleasant, and in no acute distress at this time. He answers questions appropriately.,HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Sclerae are clear. TMs clear. Oropharynx is clear.,NECK: Supple with full range of motion. He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR: Regular rate and rhythm without murmur.,LUNGS: Clear bilaterally.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Show no clubbing, cyanosis or edema.,NEUROLOGIC: He does have a minimally slurred speech at present. He does have a slight facial droop. He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA: ,His initial blood work, PT was 11 and PTT 27. CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG. CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT. Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal. He underwent an echocardiogram in the emergency room, which was essentially normal. He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1. Cerebrovascular accident, in progress." }

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

{ "text_length": 4416 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1. Deformity, right breast reconstruction.,2. Excess soft tissue, anterior abdomen and flank.,3. Lipodystrophy of the abdomen.,PROCEDURES:,1. Revision, right breast reconstruction.,2. Excision, soft tissue fullness of the lateral abdomen and flank.,3. Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:, The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction. She now had lateralization of the implant with loss of medial fullness for which she desired correction. It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length. The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected. She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such. The above-noted procedure was discussed with the patient in detail. The risks, benefits and potential complications were discussed. She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position. Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion. The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear. At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached. This was then opened. The implant was removed and placed on the back table in antibiotic solution. Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast. The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form. The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant. The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness. With this completed, the implant was again removed, antibiotic irrigation was performed. A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed. The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures. The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture. Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours. This was closed with 6-0 Prolene suture. The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus. A Kerlix dressing and a surgical bra was placed to the chest area. A compressive garment was placed. The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition. Sponge, needle, lap, instrument counts were all correct. The patient tolerated the procedure well. There were no complications. The estimated blood loss was approximately 25 mL." }

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

{ "text_length": 4015 }

{ "text": "CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glans penis. Next, incision line was marked circumferentially on the outer skin 3 mm below the corona. The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia. Next, the foreskin was retracted. Another circumferential incision was made 3 mm proximal to the corona. The intervening foreskin was excised. Meticulous hemostasis was obtained with electrocautery. Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock. The stitches were placed equal distance among these to reapproximate all the skin edges. Next, good cosmetic result was noted with no bleeding at the end of the procedure. Vaseline gauze, Telfa, and Elastoplast dressing was applied. The stay-stitch was removed and pressure held until bleeding stopped. The patient tolerated the procedure well and was returned to the recovery room in stable condition." }

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

{ "text_length": 1267 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia. The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME: ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:, None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL: ,The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered. The patient received Ancef preoperatively. Bilateral nonsterile tourniquets were placed on each thigh. A bump was placed underneath the left buttock. Both the extremities were then prepped and draped in standard surgical fashion. Attention was first turned towards the left side. Intended incision was marked on the skin. The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view. The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg. Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint. The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally. Once the foot was reduced a Steinman pin was used to hold it in position. This position was first checked on the fluoroscopy. The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction. This was also checked with fluoroscopy. The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half. This was sutured using 2-0 Ethibond and that was also oversewn. The wound was irrigated with normal saline. The periosteal flap was sutured over the staple using 2-0 Vicryl. Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl. The area was injected with 6 mL of 0.25% Marcaine local anesthetic. The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril. Tourniquet was released after 53 minutes. The exact same procedure was repeated on the right side with no changes or complications. Tourniquet time on the right side was 45 minutes. The patient tolerated the procedure well. Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch. The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request. The patient is to be strict nonweightbearing for at least 6 weeks. He is to follow up in the next 10 days for a check. We will plan of changing to short-leg casts in about 4 weeks postop." }

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

{ "text_length": 3982 }

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

{ "text_length": 4896 }

{ "text": "PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur." }

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

{ "text_length": 2649 }

{ "text": "ADMITTING DIAGNOSES:,1. Fever.,2. Otitis media.,3. Possible sepsis.,HISTORY OF PRESENT ILLNESS: ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission. He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise. He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Tympanic membranes were red and yellow, and opaque bilaterally. Nares were patent. Oropharynx was slightly moist and pink. Neck was soft and supple without masses. Heart is regular rate and rhythm without murmurs. Lungs showed increased workup of breathing, moderate tachypnea. No rales, rhonchi or wheezes were noted. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Neurologic exam showed good muscle strength, normal tone. Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits. White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. Urinalysis was completely unremarkable. Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet. Activity is as tolerates. CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered. Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%. Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration. He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers. Overnight, he did have his oxygen saturations drop and went into oxygen overnight. His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. The nurses were instructed to attempt to wean O2 if possible and advance the diet. He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient. He did well the following evening with no further oxygen requirement. He continued to spike fevers but last fever was around 13:45 on the previous day. At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs. He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night. He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1. Bilateral otitis media.,2. Fever.,PLAN: ,Recommended discharge. No restrictions in diet or activity. He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday. Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy." }

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

{ "text_length": 3925 }

{ "text": "DESCRIPTION OF PROCEDURE:, After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table. After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty. The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally. Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants. A lens ring was secured to the eye using 7-0 Vicryl suture." }

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

{ "text_length": 801 }

{ "text": "HISTORY: , The patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis. The patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised. Parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal. The patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate. Parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis. The patient is exclusively breast fed and feeding approximately 2 hours. Upon arrival at Children's Hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine. The electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor R-wave progression, possible right ventricular hypertrophy.,FAMILY HISTORY:, Family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,REVIEW OF SYSTEMS: , A complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,PHYSICAL EXAMINATION:,GENERAL: Physical examination that showed a sedated, acyanotic infant who is in no acute distress.,VITAL SIGNS: Heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,HEENT: Normocephalic with no bruit detected. She had symmetric shallow breath sounds clear to auscultation. She had full symmetrical pulses.,HEART: There is normoactive precordium without a thrill. There is normal S1, single loud S2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,ABDOMEN: Soft. Liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,X-RAYS:, Review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings. There is a prominent thymus. An echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle. The left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle. There is a large inlet ventricular septal defect as pulmonary atresia. The aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch. There was a small vertical ductus as a sole source of pulmonary artery blood flow. The central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter. Biventricular function is well maintained.,FINAL IMPRESSION: , The patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function. The saturations are now also adequate on prostaglandin E1.,RECOMMENDATION: , My recommendation is that the patient be continued on prostaglandin E1. The patient's case was presented to the cardiothoracic surgical consultant, Dr. X. The patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence. A consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention. The patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow. Further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible Rastelli procedure. The current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional Glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age. These findings and recommendations were reviewed with the parents via a Spanish interpreter." }

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

{ "text_length": 4619 }

{ "text": "CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:, After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. The patient was placed in the prone position and standard ASA monitors applied. Intravenous access was established and IV sedation was used. For further details of IV sedation and infusion, please refer to anesthesia notes. The patient was able to respond appropriately throughout the procedure. * Fluoroscopy was used to identify the appropriate anatomy. The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:, The patient was laid supine. Oblique placement was achieved by placing pillow below the shoulder and turning the head. The C# neural foramina was identified by counting down from the C2-3 foramen. The external carotid artery was marked off by palpation. The neck was aseptically prepared. 1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C# neural foramen under fluoroscopic control. The posterior inferior edge of the foramen bone was contacted. The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters. Care was taken to remain in the posterior inferior edge of the foramen. Positioning was checked by AP view, in which the needle tip extended no further medially than the midpoint of the adjacent pedicle. 1 mL of contrast was used to confirm position under fluoroscopy after aspiration. Acceptable dye pattern was seen. Subsequent 1 mL of 1% lidocaine was injected after aspiration and the patient was monitored. No adverse affects with 1% lidocaine were noted and subsequently 1 mL of Celestone was injected. Compression bandage was applied to the neck and no complications were noted.,POSTPROCEDURE EVALUATION:, After a 30-minute recovery period, during which no complications were noted, the patient was discharged home. Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95% with no respiratory distress observed." }

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

{ "text_length": 2164 }

{ "text": "EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE: ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age. There are no extraaxial fluid collections. There is no hydrocephalus/midline shift. Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits. The normal vascular flow volumes are maintained. The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain. Specifically, no findings to explain the patient's headaches are identified." }

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

{ "text_length": 785 }

{ "text": "PREOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,POSTOPERATIVE DIAGNOSIS:, T11 compression fracture with intractable pain.,OPERATION PERFORMED:, Unilateral transpedicular T11 vertebroplasty.,ANESTHESIA:, Local with IV sedation.,COMPLICATIONS:, None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Using AP and lateral fluoroscopic projections the T11 compression fracture was identified. Starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the T11 pedicle on the left. The 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle. At this point using AP and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times. Once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body. At this point polymethylmethacrylate was mixed for 60 seconds. Once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body. It was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra. A total 1.2 cc of cement was injected. On lateral view, the cement crushed to the right side as well. There was some dye infiltration into the disk space. There was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,At this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space. Once the needle was withdrawn safely pressure was held over the site for three minutes. There were no complications. The patient was taken back to the recovery area in stable condition and kept flat for one hour. Should be followed up the next morning." }

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

{ "text_length": 2297 }

{ "text": "ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:, Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:, None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008. Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident. He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters. The patient denies any loss of consciousness. He was not amnestic to the event. He was taken by family members to the Iredell County Hospital, where he was initially evaluated. Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture. No other apparent injuries. This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment. The left upper extremity x-ray did demonstrate an open left distal humerus fracture. The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture. In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture. In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures. Throughout the duration of the procedure, the patient had a palpable distal radial pulse. The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture. A wound VAC was then placed over the wound at the conclusion of the procedure. The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring. His diet was advanced and his pain was controlled with pain medication. The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident. A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point. Once his C spine had been cleared and the absence of a closed head injury was confirmed. The patient was then transferred from the Intensive Care Unit to the General Floor bed. His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound. He again tolerated this procedure well on his return to the General Pediatrics Floor. Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries. However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity. Moreover, the patient had no complaints of paresthesia. There was no demonstration of pallor or pain on passive motion. There was good capillary refill to the digits of the left hand. By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well. He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies. He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1. Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2. Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3. Negative pressure wound dressing (July 23, 2008).,4. Irrigation and debridement of left elbow fracture (July 26, 2008).,5. CT of the brain without contrast (July 24, 2008).,DISPOSITION: ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS: ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity. He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics. Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand." }

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

{ "text_length": 4893 }

{ "text": "CHIEF COMPLAINT:, Questionable foreign body, right nose. Belly and back pain. ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. He is afebrile.,GENERAL: This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT: TMs, canals are normal. Left naris normal. Right naris, there is some foul odor as well as questionable purulent drainage. Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. There was some erythema. No other purulent drainage noted. There was some bloody drainage. This was suctioned and all mucous membranes were visualized and are negative.,NECK: Without lymphadenopathy. No other findings.,HEART: Regular rate and rhythm.,LUNGS: Clear to auscultation.,ABDOMEN: His abdomen is entirely benign, soft, nontender, nondistended. Bowel sounds active. No organomegaly or mass noted.,BACK: Without any findings. Diaper area normal.,GU: No rash or infections. Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine. Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. There was a little bit of blood from catheterization but otherwise normal urine. X-ray noted some stool within the vault. Child is acting normally. He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1. Infected foreign body, right naris.,2. Mild constipation.,PLAN:, As far as the abdominal pain is concerned, they are to observe for any changes. Return if worse, follow up with the primary care physician. The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d. Return as needed and observe for more foreign bodies. I suspect, the child had placed this cotton ball in his nose again after the first episode." }

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

{ "text_length": 3600 }

{ "text": "SUBJECTIVE: , The patient states that she feels better. She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia. Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen. There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center. The aortic stenosis was secondary to a congenital bicuspid valve, by her description. She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition. She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days. Last night, she had a prolonged episode for which she contacted EMS. Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day. She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively. She states that she has been taking her aspirin at 325 mg q.a.m. She remains on Zyrtec 10 mg q.a.m. Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS: Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60. The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL: She is alert and in no apparent distress.,HEENT: Eyes: EOMI. PERRLA. Sclerae nonicteric. No lesions of lids, lashes, brows, or conjunctivae noted. Funduscopic examination unremarkable. Ears: Normal set, shape, TMs, canals and hearing. Nose and Sinuses: Negative. Mouth, Tongue, Teeth, and Throat: Negative except for dental work.,NECK: Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST: Lungs are clear bilaterally to auscultation. The incision is well healed and without evidence of significant cellulitis.,HEART: Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub. There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN: Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES: Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC: Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function. Gait and station were not tested.,MENTAL STATUS: Shows the patient to be alert, coherent with full capacity for decision making.,BACK: Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000. INR 1.0. Electrolytes are normal with exception potassium 3.3. GFR is decreased at 50 with creatinine of 1.1. Glucose was 119. Magnesium was 2.3. Phosphorus 3.8. Calcium was slightly low at 7.8. The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge. Troponin is negative x2 from 2100 and repeat at 07:32. This morning, her BNP was 163 at admission. Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion. Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds. Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient. I contacted Dr. Varner and we reviewed the patient's managed to this point. All combined impression is that the patient was likely to not have had actual ventricular tachycardia. This is based on her EP study from October showing her to be non-inducible. In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease. What is most likely that the patient has postoperative atrial fibrillation. Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely. At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period. I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated. Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1. Atrial fibrillation with rapid ventricular response.,2. Wolff-Parkinson White Syndrome.,3. Recent aortic valve replacement with bioprosthetic Medtronic valve.,4. Hyperlipidemia." }

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

{ "text_length": 4970 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,FINAL DIAGNOSIS: ,Symptomatic disk herniation, C7-T1.,PROCEDURES PERFORMED,1. Anterior cervical discectomy with decompression of spinal cord C7-T1.,2. Anterior cervical fusion, C7-T1.,3. Anterior cervical instrumentation, anterior C7-T1.,4. Insertion of intervertebral device, C7-T1.,5. Use of operating microscope.,ANESTHESIOLOGY: , General endotracheal.,ESTIMATED BLOOD LOSS: ,A 30 mL.,PROCEDURE IN DETAIL: ,The patient was taken to the operating room where he was orally intubated by The Anesthesiology Service. He was placed in the supine position on an OR table. His arms were carefully taped down. He was sterilely prepped and draped in the usual fashion.,A 4-cm incision was made obliquely over the left side of his neck. Subcutaneous tissue was dissected down to the level of the platysma. The platysma was incised using electrocautery. Blunt dissection was done to create a plane between the strap muscles and the sternoclavicular mastoid muscle. This allowed us to get right down on to the anterior cervical spine. Blunt dissection was done to sweep off the longus colli. We isolated the C7-T1 interspace. An x-ray was taken to verify; we were indeed at the C7-T1 interspace.,Shadow-Line retractor was placed as well as Caspar pins. This provided very, very good access to the C7-T1 disk.,At this point, the operating microscope was brought into the decompression.,A thorough and aggressive C7-T1 discectomy was done using a succession of curettes, pituitary rongeur, 4-mm cutting bur and a #2 Kerrison rongeur. At the end of the discectomy, the cartilaginous endplates were carefully removed using 4-mm cutting burr. The posterior longitudinal ligament was carefully resected using #2 Kerrison rongeur. Left-sided C8 foraminotomy was accomplished using nerve hook and a 2-mm Kerrison rongeur. At the end of the decompression, there was no further compression on the left C8 nerve root.,A Synthes cortical cancellous ____________ bone was placed in the interspace. Sofamor Danek Atlantis plate was then placed over the interspace and four screws were placed, two in the body of C7 and two in the body of T1. An x-ray was taken. It showed good placement of the plate and screws.,A deep drain was placed. The platysma layer was closed in running fashion using #1 Vicryl. Subcutaneous tissue was closed in an interrupted fashion using 2-0 Vicryl. Skin was closed in a running fashion using 4-0 Monocryl. Steri-Strips and dressings were applied. All counts were correct. There were no complications." }

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

{ "text_length": 2599 }