Datasets:

Luggi

/

medspec_prompt

like 0

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1. Left thoracoscopy.,2. Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:, Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION: ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray. Preoperative evaluation included a CT scan, which showed focal mass. CT and PET confirmed anterior lesion. Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction. In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly. She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty. She was sedated and intubated with double-lumen endotracheal tube without difficulty. She was positioned with left side up. Appropriate pressure points were padded. The left chest was prepped and draped in the standard surgical fashion. The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered. There was good deflation of the left lung. __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning. Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall. There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified. The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm. It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion. Camera was placed through this port. Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity. Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site. This was taken down to the subcutaneous tissue with Bovie electrocautery. Periosteal elevator was used to lift the intercostal muscle off. The ribs were not spread. Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed. Prestige graspers were used to pull the specimen from the chest wall. Care was taken not to injure the capsule. The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall. Care was taken not to transect the stalk. Specimen came off the chest wall very easily. There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision. Specimen was placed in the bag and then removed from the field. There was good hemostasis. Camera was removed. A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture. The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes. The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition. ### Label: Cardiovascular / Pulmonary ### Response:

Cardiovascular / Pulmonary

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: INDICATION FOR OPERATION:, Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:, Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:, After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner. Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture. Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion. Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally. The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar. We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal. The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs. On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof. The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate. It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position. The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place. Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place. The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum. The wounds were irrigated out. A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings. The patient tolerated the procedure well and did receive blood transfusions. ### Label: Neurosurgery ### Response:

Neurosurgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,POSTOPERATIVE DIAGNOSIS: , Acquired nasal septal deformity.,PROCEDURES:,1. Open septorhinoplasty with placement of bilateral spreader grafts.,2. Placement of a radiated rib tip graft.,3. Placement of a morcellized autogenous cartilage dorsal onlay graft.,4. Placement of endogen, radiated collagen dorsal onlay graft.,5. Placement of autogenous cartilage columellar strut graft.,6. Bilateral lateral osteotomies.,7. Takedown of the dorsal hump with repair of the bony and cartilaginous open roof deformities.,8. Fracture of right upper lateral cartilage.,ANESTHESIA: ,General endotracheal tube anesthesia.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,100 mL.,URINE OUTPUT:, Not recorded.,SPECIMENS:, None.,DRAINS: , None.,FINDINGS: ,1. The patient had a marked dorsal hump, which was both bony and cartilaginous in nature.,2. The patient had marked hypertrophy of his nasalis muscle bilaterally contributing to the soft tissue dorsal hump.,3. The patient had a C-shaped deformity to the left before he had tip ptosis.,INDICATIONS FOR PROCEDURE: , The patient is a 22-year-old Hispanic male who is status post blunt trauma to the nose approximately 9 months with the second episode 2 weeks following and suffered a marked dorsal deformity. The patient was evaluated, but did not complain of nasal obstruction, and his main complaint was his cosmetic deformity. He was found to have a C-shaped deformity to the left as well as some tip ptosis. The patient was recommended to undergo an open septorhinoplasty to repair of this cosmetic defect.,OPERATION IN DETAIL: , After obtaining a full consent from the patient, identified the patient, prepped with Betadine, brought to the operating room and placed in the supine position on the operating table. The appropriate Esmarch was placed; and after adequate sedation, the patient was subsequently intubated without difficulty. The endotracheal tube was then secured, and the table was then turned clockwise to 90 degrees. Three Afrin-soaked cottonoids were then placed in nasal cavity bilaterally. The septum was then injected with 3 mL of 1% lidocaine with 1:100,000 epinephrine in the subperichondrial plane bilaterally. Then, 50 additional mL of 1% lidocaine with 1:100,000 epinephrine was then injected into the nose in preparation for an open rhinoplasty.,Procedure was begun by first marking a columellar incision. This incision was made using a #15 blade. A lateral transfixion incision was then made bilaterally using a #15 blade, and then, the columellar incision was completed using iris scissors with care not to injure the medial crura. However, there was a dissection injury to the left medial crura. Dissection was then taken in the subperichondrial plane over the lower lateral cartilages and then on to the upper lateral cartilage. Once we reached the nasal bone, a Freer was used to elevate the tissue overlying the nasal bone in a subperiosteal fashion. Once we had completed exposure of the bony cartilaginous structures, we appreciated a very large dorsal hump, which was made up of both a cartilaginous and bony portions. There was also an obvious fracture of the right upper lateral cartilage. There was also marked hypertrophy what appeared to be in the nasalis muscle in the area of the dorsal hump. The skin was contributing to the patient's cosmetic deformity. In addition, we noted what appeared to be a small mucocele coming from the area of the fractured cartilage on the right upper lateral cartilage. This mucocele was attempted to be dissected free, most of which was removed via dissection. We then proceeded to remove takedown of the dorsal hump using a Rubin osteotome. The dorsal hump was taken down and passed off the table. Examination of the specimen revealed the marking amount of scar tissue at the junction of the bone and cartilage. This was passed off to use later for possible onlay grafts. There was now a marked open roof deformity of the cartilage and bony sprue. A septoplasty was then performed throughout and a Kelly incision on the right side. Subperichondrial planes were elevated on the right side, and then, a cartilage was incised using a caudal and subperichondrial plane elevated on the left side. A 2 x 3-cm piece of the cardinal cartilage was then removed with care to leave at least 1 cm dorsal and caudal septal strut. This cartilage was passed down the table and then 2 columellar strut grafts measuring approximately 15 mm in length were then used and placed to close the bony and cartilaginous open roof deformities. The spreader grafts were sewn in place using three interrupted 5-0 PDS sutures placed in the horizontal fashion bilaterally. Once these were placed, we then proceeded to work on the bony open roof. Lateral osteotomies were made with 2-mm osteotomes bilaterally. The nasal bones were then fashioned medially to close the open roof deformity, and this reduced the width of the bony nasal dorsum. We then proceeded to the tip. A cartilaginous strut was then fashioned from the cartilaginous septum. It was approximately 15 mm long. This was placed, and a pocket was just formed between the medial crura. This pocket was taken down to the nasal spine, and then, the strut graft was placed. The intradermal sutures were then placed using interrupted 5-0 PDS suture to help to provide more tip projection and definition. The intradermal sutures were then placed to help to align the nasal tip. The cartilage strut was then sutured in place to the medial crura after elevating the vestibular skin off the medial crura in the area of the plane suturing. Prior to the intradermal suturing, the vestibular skin was also taken off in the area of the dome.,The columellar strut was then sutured in place using interrupted 5-0 PDS suture placed in a horizontal mattress fashion with care to help repair the left medial crural foot. The patient had good tip support after this maneuver. We then proceeded to repair the septal deformity created by taking down the dorsal hump with the Rubin osteotome. This was done by crushing the remaining cartilage in the morcellizer and then wrapping this crushed cartilage in endogen, which is a radiated collagen. The autogenous cartilage was wrapped in endogen in a sandwich fashion, and then, a 4-0 chromic suture was placed through this to help with placement of the dorsal onlay graft.,The dorsal onlay was then sewn into position, and then, the 4-0 chromic suture was brought out through this externally to help the superior placement of the dorsal onlay graft. Once we were happy with the position of the dorsal onlay graft, the graft was then sutured in place using two interrupted 4-0 fast-absorbing sutures inferiorly just above the superior edge of the lower lateral cartilages. Once we were happy with the placement of this, we did need to take down some of the bony dorsal hump laterally, and this was done using a #6 and then followed with a #3 push grafts. This wrapping was performed prior to placement of the dorsal onlay graft.,I went through content with the dorsal onlay graft and the closure of the roof deformities as well as placement of the columellar strut, we then felt the patient could use a bit more tip projection; and therefore, we fashioned a radiated rib into a small octagon; and this was sutured in place over the tip using two interrupted 5-0 PDS sutures.,At this point, we were happy with the test results, although the patient did have significant amount of fullness in the dorsal hump area due to soft tissue thick and fullness. There do not appear to be any other pathology causing the patient dorsal hump and therefore, we felt we have achieved the best cosmetic result at this point. The septum was reapproximated using a fast-absorbing 4-0 suture and a Keith needle placed in the mattress fashion. The Kelly incision was closed using two interrupted 4-0 fast-absorbing gut suture. Doyle splints were then placed within the nasal cavity and secured to the inferior septum using a 3-0 monofilament suture. The columellar skin was reapproximated using interrupted 6-0 nylon sutures, and the marginal incision of the vestibular skin was closed using interrupted 4-0 chromic sutures.,At the end of the procedure, all sponge, needle, and instrument counts were correct. A Denver external splint was then applied. The patient was awakened, extubated, and transported to Anesthesia Care Unit in good condition. ### Label: ENT - Otolaryngology ### Response:

ENT - Otolaryngology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:, We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable. No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS: ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position. The patient underwent a Bier block by the Department of Anesthesia on the upper extremity. The upper extremity was prepped and draped in usual sterile fashion and left free. Attention was drawn then to the palm of the hand. We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel. Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves. Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel. We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament. We found no evidence of tumor or space occupying lesion in the carpal tunnel. We then irrigated copiously. Tourniquet was taken down at that time and pressure was held. There was no evidence of obvious bleeders. We approximated the skin with nylon and placed a postoperative dressing with a volar splint. The patient tolerated the procedure well. She was placed back in the gurney and taken to PACU. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay. He had left hip fracture identified on x-rays at that time. Pain and inability to ambulate brought him in. He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia. His medical issues are under good control. The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03. The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension. Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy. He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties.,ALLERGIES:, Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1. Heparin.,2. Albuterol inhaler.,3. Combivent.,4. Aldactone.,5. Doxepin.,6. Xanax.,7. Aspirin.,8. Amiodarone.,9. Tegretol.,10. Synthroid.,11. Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there. Speech and language pathology following with current swallowing dysfunction. He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:, Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT: Oropharynx clear.,CV: Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally.,ABDOMEN: Nontender, nondistended. Bowel sounds positive.,EXTREMITIES: Without clubbing, cyanosis, or edema.,NEUROLOGIC: There are no focal motor or sensory losses to the lower extremities. Bulk and tone normal in the lower extremities. Wound site has healed well with staples out.,IMPRESSION ,1. Status post left hip fracture and hemiarthroplasty.,2. History of panic attack, anxiety, depression.,3. Myocardial infarction with stent placement.,4. Hypertension.,5. Hypothyroidism.,6. Subdural hematoma.,7. Seizures.,8. History of chronic obstructive pulmonary disease. Recent respiratory insufficiency.,9. Renal insufficiency.,10. Recent pneumonia.,11. O2 requiring.,12. Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared. ### Label: Orthopedic ### Response:

Orthopedic

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison is made with the prior CT abdomen and pelvis dated 10/20/05. There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP. Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips. The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen. There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak. Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either. No exoluminal leakage is identified at any level. There is no retroperitoneal hematoma present. The findings are unchanged from the prior exam. ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present. There is advanced atrophy of the left kidney. No hydronephrosis is present. No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified. There is prominent streak artifact from the left total hip replacement. There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis. The bladder grossly appears normal. A hysterectomy has been performed. ,IMPRESSION:,1. No complications identified regarding endoluminal aortoiliac graft repair as described. The findings are stable compared to the study of 10/20/04. ,2. Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level. ,3. No other acute findings noted. ,4. Advanced left renal atrophy. ### Label: Gastroenterology ### Response:

Gastroenterology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS: , Right failed total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: ,Right failed total knee arthroplasty.,PROCEDURE PERFORMED: , Revision right total knee arthroplasty.,FIRST ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Approximately 75 cc.,TOURNIQUET TIME: , 123 minutes. Then it was let down for approximately 15 minutes and then reinflated for another 26 minutes for a total of 149 minutes.,COMPONENTS: , A Zimmer NexGen Legacy knee size D right stemmed femoral component was used. A NexGen femoral component with a distal femoral augmented block, size 5 mm. A NexGen tibial component, size 3 mm was used. A size 14 mm constrained polyethylene surface was used as well. Original patellar component that the patient had was maintained.,COMPLICATIONS: ,None.,BRIEF HISTORY:, The patient is a 68-year-old female with a history of knee pain for 13 years. She had previous total knee arthroplasty and revision at an outside facility. She had continued pain, snapping, malalignment, difficulty with ambulation, and giving away and wished to undergo additional revision surgery.,PROCEDURE:, The patient was taken to the operative suite and placed on the operating table. Department of Anesthesia administered the spinal anesthetic. Once adequately anesthetized, the patient was placed in a supine position. Care was ensured and she was adequately secured and well padded in position. Once this was obtained, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was inflated to approximately 325 mmHg on the right thigh. At this point, an incision was made over her anterior previous knee scar taking this down to the subcutaneous tissue of the overlying retinaculum. A medial parapatellar arthrotomy was then made by using a second knife and this was taken both distally and proximally to allow us to sublux the patella on the lateral aspect to allow exposure to the joint surface. There was noted to be no evidence of purulence or gross clinical appearance of infection, however, intraoperative cultures were taken to asses this as well. At this point, the previous articular surface was then removed using an osteotome until this was left free and then removed. This was done without difficulty. Attention was then directed removing the femoral component. Osteotome was taken around each of the edges until this was gently lifted up and then a femoral extractor was placed around it and this was back flapped until this was easily removed. After this was performed, attention was then directed to the tibial component. An osteotome was again inserted around the surface and this was easily pried loose. There was noted to be minimal difficulty with this and did not appear to have adequate cement fixation. This was evaluated. The bone stalk appeared to be adequate, however, there were noted to be some deficits where we need to trim cement, so we elected to proceed with stemmed component. The attention was first directed to the femur and the femoral canal was opened up and superficially reamed up to a size 18 mm proximal portion for the Zimmer stemmed component. At this point, the distal femoral cut was evaluated with a intramedullary guide and this was noted to be cut in a varus cut leaving us a large deficit of the medial femoral cut. We elected because of this large amount of retic to take off the medial condyle to correct this varus cut to a six degree valgus cut. We elected to augment the medial aspect and take only 5 mm off of the lateral condyle instead of a full 10 to 12. At this point, the distal femoral cutting guide based on the intramedullary head was then placed. Care was ensured that this was aligned in proper rotation with the external epicondylar axis. Once this was pinned in position, approximately a six degree valgus cut was then made. This allowed a portion of the medial condyle to be removed distally. The anterior cut was checked next using the intramedullary guide. The anterior surface cutting block was then placed. This aligned us to anterior cutting block.,We ensured again that rotation was aligned with the epicondylar axis. Once this was adequately aligned with this and gave us some external rotation, this was pinned in position and new anterior cut was made. It was noted that minimal bone was taken off the surface, only a slight portion on the medial anterior surface. _______ was then removed and the chamfer cutting guide was then placed on. This allowed us to make a box cut and recut some of the angled cuts of the distal femur. Once this was placed and pinned in position. Care was then again taken to check that this was in proper rotation and then the chamfer cuts were recut. It was noted that the anterior chamfers did not need to be cut, take off no bone. The posterior chamfers did remove some bony aspects. This was also taken off some of the posterior aspects of the condyles and then the ossicle saw and reciprocal saw were used to take off a notch cut to open up a constrained component. After all these cuts were taken, the guides were then removed and the trial component with a medial 5 mm augment was then placed. This appeared to have an adequate fit and then packed in position. It appeared to be satisfactory. At this point, this was removed and attention was then directed to the tibia. The intramedullary canal was again opened up using a proximal drill and this was reamed to the appropriate size until good _______ was obtained. At this point, the intramedullary guide was used to evaluate a tibial cut. This appeared to be adequate, however, we elected to remove 2 mm of bone to give us a new fresh bony surface. The cutting guide was placed in adequate alignment and checked both the with intramedullary guide and an external alignment rod, which allowed us to ensure that we had proper external rotation of this tibial component. At this point, this was pinned in position and the tibial cut was made to remove an extra 2 mm of bone. This was again removed and a trial tibial stemmed component was then placed as well as the trial augmented stemmed femoral component. This was placed in a proper position. A 10 mm articular surface was placed in the knee and this was taken through range of motion. This was found to have better alignment and satisfactory position. We elected to take an intraoperative x-ray at this point, to evaluate our cut. The intraoperative x-ray demonstrates satisfactory cuts and alignment of the prosthesis. At this point, all trials were removed. The patella was then examined. The rongeur was used to remove the surrounding synovium. The patella was evaluated and found to have mild wear on the lateral aspect of the inferior butt, however, this was very mild and overall had a good position and was well fixed to the bone. It was elected at this time to maintain this anatomic patella that was previously placed. At this point, the joint again was reevaluated and any bone loose fragments removed. There was noted to be some posterior tightness and mild osteophytes. These were removed with a rongeur.,At this time, while preparing the canals, the tourniquet was deflated due to it being 123 minutes. Approximately 10 minutes did get by, as the knee was copiously irrigated and suctioned dried. The tourniquet was then reinflated. The canals were prepped for cementing. They were suction-dried and cleaned. The tibial component was cemented and then impacted into position and ensured it was adequately aligned in proper external rotation and alignment that was previously tried with the trial. Once this was fixed and secured, all extra cement was removed and attention was directed to the femoral component. The stemmed femoral component was then impacted in position and cemented. Again care was ensured that it was in adequate position and proper rotation. A size 14 mm poly was then inserted in between to provide compression. This was then taken through extension and held until cement cured. This was then removed and the components were evaluated. All excess cement was removed and they were well fixed. Size 14 mm trial Poly was then placed and this was taken through range of motion. This was found to have excellent range of motion and good stability. It was elected at this time that we would go with the size 14 mm Poly. This gave us extra Poly for ware and then provide excellent contact throughout the range of motion. The final articular surface was then placed and tightened into position to allow to _______ secured. The knee was then reduced and the knee was taken through range of motion. The patella was tracking with no-touch technique and adequately positioned. At this point, the tourniquet was deflated for second time and then the knee was copiously irrigated and suctioned dry. All bleeding was cauterized using a Bovie cautery. The retinaculum was then repaired using #1 Ethibond in a figure-of-eight fashion. This was reinforced with a running #2-0 Vicryl. The knee was then flexed and noted that the patella was tracking with good alignment. The wound was again copiously irrigated and suctioned dry. A drain was placed prior to retinaculum repair deep to this to provide adequate drainage. At this point, the subcutaneous tissue was closed with #2-0 Vicryl. Skin was approximated with skin clips. Sterile dressing of Adaptic, 4x4, Webril, and ABDs were then placed. A large Dupre dressing was then placed up the entire lower extremity. The patient was then transferred back to recovery in supine position.,DISPOSITION: , The patient tolerated the procedure well with no complications and transferred to PACU in satisfactory condition. ### Label: Orthopedic ### Response:

Orthopedic

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS:, Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS: ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance. She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY: ,The patient was brought to the operative suite and placed supine on the operating room table. General anesthetic was administered. Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy. He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx. Under an operating headlight, the oropharynx was clearly visualized. The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa. This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris. Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts. With the tonsils removed, it was possible to visualize the adenoid pads. The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique. The adenoid pad was greater than 2+/4 and hypertrophic. It was removed with successive passes of electrocautery suction. The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle. The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period. The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic. She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal. There were no complications. Specimens produced were right and left tonsils. The adenoid pad was ablated with electrocautery. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed. Questions were answered. Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. The ileocecal valve looked normal. Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope. The terminal ileum was intubated through the ileocecal valve for a 5 cm extent. Terminal ileum mucosa looked normal.,Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum. No polyp, no diverticulum and no bleeding source was identified.,The patient was assessed upon completion of the procedure. Okay to discharge once criteria met. ,RECOMMENDATIONS:, Follow up with primary care physician. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. This has required large amounts of opioid analgesics to control. She has been basically bedridden because of this. She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. Difficult to assess individual muscles, but strength is largely intact. Sensory examination is symmetric. Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. She has slightly decreased right versus left ankle reflexes. The Babinski's are positive. On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal. It reveals the following:,1. Inactive right S1 (L5) radiculopathy.,2. There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day. ### Label: Neurology ### Response:

Neurology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: 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 ### Response:

SOAP / Chart / Progress Notes

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments. The GIF-160 diagnostic gastroscope used. The patient was alert during the procedure. The esophagus was intubated under direct visualization. The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted. The stomach was unremarkable. Retroflexed exam unremarkable. Duodenum not intubated in order to minimize the time spent during the procedure. The patient was alert although not combative. A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds. The balloon was then deflated. The patient became uncomfortable and a good-size adequate distal esophageal tear was noted. The scope and balloon were then withdrawn. The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed. This has been discussed with the parents. He was sent home with a prescription for omeprazole. ### Label: Gastroenterology ### Response:

Gastroenterology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia. ### Label: Cardiovascular / Pulmonary ### Response:

Cardiovascular / Pulmonary

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURE PERFORMED: ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:, After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing. The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion. 1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein. Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein. A steel guidewire was inserted through the needle into the vascular lumen without resistance. The needle was then removed over the guidewire and the guidewire was secured to the field. A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen. Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field. Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area. A #11-knife blade was used to make a deeper incision. Hemostasis was made complete. The edges of the incision were grasped and retracted. Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane. Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator. Metzenbaum scissors were then used to dissect cephalad to expose the guide wires. The guidewires were then pulled through the pacemaker pocket. One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance. The guidewire and dilator were then removed. Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium. The pacemaker lead was then placed in the appropriate position in the right ventricle. Pacing and sensing thresholds were obtained. The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________. Pacing and sensing threshold were then reconfirmed. Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen. The guidewire and dilator were then removed. Under fluoroscopic guidance, the atrial lead was passed into the right atrium. The sheath was then turned away in standard fashion. Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position. Pacing and sensing thresholds were obtained. The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________. Sensing and pacing thresholds were then reconfirmed. The leads were wiped free of blood and placed into the pacemaker generator. The pacemaker generator leads were then placed into pocket with the leads posteriorly. The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion. A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch. Steri-Strips overlaid. A sterile gauge dressing was placed over the site. The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer: Medtronics.,Model: Sigma.,Model #: 1234.,Serial #: 123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,VENTRICULAR LEAD:,Manufacturer: Medtronics.,Model #: 1234.,Serial #: 123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead: Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead: Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:, Pacing mode DDDR: Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:, Successful implantation of DDDR permanent pacemaker.,PLAN:,1. The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2. The patient will be placed on antibiotics for five days to avoid pacemaker infection. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks "un poquito" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a "stacker." He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had "a little" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under "previous occurrence of the same pain" a notation of "Yes, but it was not really the same, it was just a little and tolerable." There is an additional note on the side which states "no pain prior to this injury or on that day, occasional (but low back)." Saw this notation, he says today that he did not state this and that the form was done by "Edna" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty "moving." He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has "good and bad days" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a "tightness" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:, AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.). ### Label: IME-QME-Work Comp etc. ### Response:

IME-QME-Work Comp etc.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,POSTOPERATIVE DIAGNOSES,Airway obstruction secondary to severe subglottic tracheal stenosis with foreign body in the trachea.,OPERATION PERFORMED,Neck exploration; tracheostomy; urgent flexible bronchoscopy via tracheostomy site; removal of foreign body, tracheal metallic stent material; dilation distal trachea; placement of #8 Shiley single cannula tracheostomy tube.,INDICATIONS FOR SURGERY,The patient is a 50-year-old white male with history of progressive tracheomalacia treated in the National Tennessee, and several years ago he had a tracheal metallic stent placed with some temporary improvement. However developed progressive problems and he had two additional stents placed with some initial improvement. Subsequently, he developed progressive airway obstruction and came into the ABC Hospital critical airway service for further evaluation and was admitted on Month DD, YYYY. He underwent bronchoscopy by Dr. W and found to have an extensive subglottic upper tracheal and distal tracheal stenosis secondary to metallic stent extensive granulation and inflammatory tissue changes. The patient had some debridement and then was hospitalized and Laryngology and Thoracic Surgery services were consulted for further management. Exploration of trachea, removal of foreign body stents constricting his airway, dilation and stabilization of his trachea were offered to the patient. Nature of the proposed procedure including risks and complications of bleeding, infection, alteration of voice, speech, swallowing, voice changes permanently, possibility of tracheotomy temporarily or permanently to maintain his airway, loss of voice, cardiac risk factors, anesthetic risks, recurrence of problems, upon surgical intervention were all discussed at length. The patient stated that he understood and wished to proceed.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room, placed in the supine position. Following adequate monitoring by Anesthesia Service to maintain sedation, the patient's neck was prepped and draped in the sterile fashion. The neck was then infiltrated with 1% Xylocaine and 1000 epinephrine. A collar incision approximately 1 fingerbreadth above the clavicle, this was an outline incision, was carried out. The skin, subcutaneous tissue, platysma, subplatysmal flaps elevated superiorly and inferiorly. Strap muscles were separated in the midline, dissection carried down to visceral fascia. Beneath the strap muscles, there was dense inflammation scarring obscuring palpable landmarks. There appeared to be significant scarring fusion of soft tissue at the perichondrium and cartilage of the cricoid making the cricoid easily definable. There was a markedly enlarged thyroid isthmus. Thyroid isthmus was divided and dense inflammation, attachment of the thyroid isthmus, fusion of the thyroid gland to the capsule to the pretracheal fascia requiring extensive blunt sharp dissection. Trachea was exposed from the cricoid to the fourth ring which entered down into the chest. The trachea was incised between the second and third ring inferior limb in the midline and excision of small ridge of cartilage on each side sent for pathologic evaluation. The tracheal cartilage externally had marked thickening and significant stiffness calcification, and the tracheal wall from the outside of the trachea to the mucosa measured 3 to 4 mm in thickness. The trachea was entered and visualized with thickening of the mucosa and submucosa was noted. The patient, however, was able to ventilate at this point a #6 Endo Tube was inserted and general anesthesia administered. Once the airway was secured, we then proceeded working around the #6 Endo Tube as well as with the tube intake and out to explore the trachea with ridged fiberoptic scopes as well as flexible fiberoptic bronchoscopy to the trach site. Examination revealed extrusion of metallic fragments from stent and multiple metallic fragments were removed from the stent in the upper trachea. A careful examination of the subglottic area showed inflamed and thickened mucosa but patent subglottis. After removal of the stents and granulation tissue, the upper trachea was widely patent. The mid trachea had some marked narrowing secondary to granulation. Stent material was removed from this area as well. In the distal third of the trachea, a third stent was embedded within the mucosa, not encroaching on the lumen without significant obstruction distally and this was not disturbed at this time. All visible stent material in the upper and mid trachea were removed. Initial attempt to place a #16 Montgomery T tube showed the distal lumen of the T tube to be too short to stent the granulation narrowing of the trachea at the junction of the anterior two thirds and the distal third. Also, this was removed and a #8 Shiley single cannula tracheostomy tube was placed after removal of the endotracheal tube. A good ventilation was confirmed and the position of the tube confirmed it to be at the level just above the metallic stent which was embedded in the mucosa. The distal trachea and mainstem bronchi were widely patent. This secured his airway and no further manipulation felt to be needed at this time. Neck wound was thoroughly irrigated and strap muscles were closed with interrupted 3-0 Vicryl. The skin laterally to the trach site was closed with running 2-0 Prolene. Tracheostomy tube was secured with interrupted 2-0 silk sutures and the patient was taken back to the Intensive Care Unit in satisfactory condition. The patient tolerated the procedure well without complication. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats. There is no blurring of the vision, itching, throat or neck pain, or neck fullness. There is no vertigo or hoarseness or painful swallowing. There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion. There is no shortness of breath and no cough or hemoptysis. No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools. No dysuria, hematuria or excessive urination. No muscle weakness or tenderness. No new numbness or tingling. No arthralgias or arthritis. There are no rashes. No excessive fatigability, loss of motor skills or sensation. No changes in hair texture, change in skin color, excessive or decreased appetite. No swollen lymph nodes or night sweats. No headaches. The rest of the review of systems is negative. ### Label: General Medicine ### Response:

General Medicine

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: Her past medical history includes a presumed diagnosis of connective tissue disorder. She has otherwise, good health. She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically. She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye. Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD. She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS. Intraocular pressures are 13 OU and by applanation. Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes. Gonioscopy showed normal anterior segment angle morphology in both eyes. She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes. Conjunctivae were quite, OU. Cornea were clear in both eyes. The anterior chamber is deep and quiet, OU. She has clear lenses, which are in good position, OU. Dilated fundus exam shows moderately optically clear vitreous, OU. The optic nerves are normal in size. The cup-to-disc ratios were approximately 0.4, OU. The nerve fiber layers are excellent, OU. The macula, vessels, and periphery were normal in both eyes. No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous. She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur. Otherwise, I can see her in 1 to 2 years. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS: ,Postsurgical changes of a left lower quadrant ileostomy are again seen. There is no evidence for an obstruction. A partial colectomy and diverting ileostomy is seen within the right lower quadrant. The previously seen 3.4 cm subcutaneous fluid collection has resolved. Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. No obstruction is seen. The appendix is not clearly visualized. The urinary bladder is unremarkable.,IMPRESSION:,1. Resolution of the previously seen subcutaneous fluid collection.,2. Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. These findings may be due to a pelvic abscess.,3. Right lower quadrant ileostomy has not significantly changed.,4. Cholelithiasis. ### Label: Radiology ### Response:

Radiology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURE IN DETAIL:, 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 a sterile ophthalmic fashion and the procedure begun. A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. The 4 rectus muscles were looped and isolated using 2-0 silk suture. The retinal periphery was then inspected via indirect ophthalmoscopy., ### Label: Ophthalmology ### Response:

Ophthalmology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: HISTORY OF PRESENT ILLNESS:, The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have hemoglobin of 9 and MCV 65. The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off. Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago. At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature. The patient also was diagnosed with lymphocytic colitis. He was not treated for diarrhea for more than 3 years.,PAST MEDICAL HISTORY: , Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.,MEDICATIONS: , Iron supplement.,ALLERGIES: ,The patient has no known drug allergies.,FAMILY HISTORY:, Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.,SOCIAL HISTORY:, The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use.,REVIEW OF SYSTEMS: , The patient has no night sweats. Good appetite. Stable weight. No chills, no fevers. No visual problems. No hearing problems. The patient denies any difficulty swallowing, any nausea or vomiting, any burning sensation in the esophagus. The patient has had chronic diarrhea for more than 3 years. His stool is daily, 1-2 times per day and very loose. He also admitted to have dark and bright blood in the stool on and off for more than 5 months. Respiratory review of systems was significant for COPD. The patient is not on oxygen and his COPD is mild. He denies any neurological problems, psychiatric problems, endocrine problems, hematological problems, lymphatic problems, immunological problems, allergy problems. The patient had recent episode of significant skin itching all over the body.,PHYSICAL EXAMINATION:,VITAL SIGNS: Weight 221 pounds. Height 6 feet 1 inch. Blood pressure 124/62, heart rate 87, temperature 98.4, saturation 98%. Pain is 0/10.,GENERAL: Well-developed, well-nourished, normal asthenic. Good attention to grooming.,HEENT: PERRLA. EOM intact. Oropharynx is clear of lesions. Good dentition.,NECK: Supple. No lymphadenopathy. No thyromegaly.,LUNGS: Clear to auscultation and percussion bilaterally. No wheezing, no rhonchi, no crackles.,CARDIOVASCULAR: Regular rate and rhythm. The patient had 2/6 systolic ejection murmur on aortic valve projected to carotid artery. No rubs, no gallops. No JVD. Peripheral pulses 2+ in both radialis and both dorsalis pedis bilaterally.,ABDOMEN: No masses, no tenderness. No distention. No hepatosplenomegaly. Bowel sounds present.,RECTAL: Good sphincter tone. No palpable nodules. No masses. No blood. Dark stool, the patient is taking iron. Test was sent for occult blood test.,BACK: No costovertebral tenderness bilaterally.,LYMPHATICS: The patient had no neck, axial, groin or supraclavicular lymphadenopathy on exam.,MUSCULOSKELETAL: The patient had good, stable gait. No clubbing, no cyanosis, no pitting edema. Full range of motion. No joint deformities.,SKIN: Clear of rashes and lesions. No ulcers.,NEUROLOGICAL: Cranial nerves II-XII within normal limits. Deep tendon reflexes 2+ in both knees and both biceps. Babinski negative bilaterally. Good control of bowel and urinary bladder. No local weakness.,PSYCHIATRIC: The patient had good judgment and insight. Oriented x4. Good recent and remote memory. Appropriate mood and affect.,ASSESSMENT & PLAN: ,The patient is a 55-year-old gentleman with iron deficiency anemia, blood in the stool. The patient needs evaluation for source of bleeding with a colonoscopy. The patient was explained rationale, risks, benefits, and alternatives of the procedure. He accepted the recommendation. Colonoscopy scheduled. The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality. The patient had multiple tests from a previous examination. One of the pathology reports from Dr. X from 2003 showed lymphocytic microscopic colitis, hyperplastic polyps. Reviewed also multiple lab tests including CBC, CMP. The patient had Coombs' test negative. His reticulocyte count is 2.41. His iron TIBC 514, serum iron 29, ferritin 7. He had no liver function test abnormality. PSA was in the normal range. The patient had x-ray which showed pulmonary hyperinflation and emphysema. The patient will be followed up with result of colonoscopy. ### Label: SOAP / Chart / Progress Notes ### Response:

SOAP / Chart / Progress Notes

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:, Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,HEMOSTASIS:, Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES: ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site. The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg. The right ankle tourniquet was then inflated. The right foot was prepped, scrubbed, and draped in normal sterile technique. Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe. The incision was deepened through the subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint. All the tendinous and neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal. Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered. Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions. Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe. Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present. The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal. The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal. The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation. The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination. The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System. The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy. The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System. The 2 screws were inserted using AO technique. Upon insertion of the screws, the two wires were removed. Fixation of the osteotomy on the table was found to be excellent. The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction. The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation. The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. Steri-Strips were used to approximate and reinforce the skin edges. At this time, the right ankle tourniquet was deflated. Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff. The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage. The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels. The patient was given instructions and education on how to continue caring for her right foot surgery at home. The patient was also given pain medication instructions on how to control her postoperative pain. The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSIS: , Follow up adenomas.,POSTOPERATIVE DIAGNOSES:,1. Two colon polyps, removed.,2. Small internal hemorrhoids.,3. Otherwise normal examination of cecum.,MEDICATIONS: , Fentanyl 150 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 60-year-old white female with a history of adenomas. She does have irregular bowel habits.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered. The colonoscope was advanced to the cecum as identified by the ileocecal valve, appendiceal orifice, and blind pouch. The colonoscope was slowly withdrawn and a careful examination of the colonic mucosa was made, including a retroflexed view of the rectum. There was a 4 mm descending colon polyp, which was removed with jumbo forceps, and sent for histology in bottle one. There was a 10 mm pale, flat polyp in the distal rectum, which was removed with jumbo forceps, and sent for histology in bottle 2. There were small internal hemorrhoids. The remainder of the examination was normal to the cecum. The patient tolerated the procedure well without complication.,IMPRESSION:,1. Two colon polyps, removed.,2. Small internal hemorrhoids.,3. Otherwise normal examination to cecum.,PLAN: , I will await the results of the colon polyp histology. The patient was told the importance of daily fiber. ### Label: Gastroenterology ### Response:

Gastroenterology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: 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: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has St. Jude permanent pacemaker. Pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. He also has a fairly advanced degree of Alzheimer's dementia and is living in an assisted care facility. The patient is unable to make his own health care decision and his daughter ABC has medical power of attorney. The patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. For this reason the Casa Grande Regional Medical Center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. Furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,PAST MEDICAL HISTORY:,1. Sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. Dementia of Alzheimer's disease.,3. Gastroesophageal reflux disease.,4. Multiple pacemaker implantation and exchanges.,FAMILY HISTORY: , Unobtainable.,SOCIAL HISTORY: , The patient resides full time at ABC supervised living facility. He is nonsmoker, nondrinker. He uses wheelchair and moves himself about with his feet. He is independent of activities of daily living and dependent on independent activities of daily living.,ALLERGIES TO MEDICATIONS: , No known drug allergies.,MEDICATIONS: ,Omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,REVIEW OF SYSTEMS: , A 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. Negative for recent falls. Positive for significant memory loss. All other review of systems is negative.,PHYSICAL EXAMINATION:,GENERAL: The patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,VITAL SIGNS: Blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,HEENT: Head atraumatic and normocephalic. Eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. Ears, nose, mouth, and throat.,NECK: Supple. No lymphadenopathy, thyromegaly, or thyroid masses appreciated.,CARDIOVASCULAR: No JVD or no jugular venous distention. No carotid bruits bilaterally. Pacemaker pocket right upper thorax with healed surgical incisions. S1 and S2 are normal. No S3 or S4. There are no murmurs. No heaves or thrills, gout, or gallops. Trace edema at dorsum of his feet and ankles. Femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,RESPIRATORY: Breath sounds are clear but diminished throughout AP diameters expanded. The patient speaks in full sentences. No wheezing, no accessory muscles used for breathing.,GASTROINTESTINAL: Abdomen is soft and nontender. Bowel sounds are active in all 4 quadrants. No palpable pulses. No abdominal bruit is appreciated. No hepatosplenomegaly.,GENITOURINARY: Nonfocal.,MUSCULOSKELETAL: Muscle strength in lower extremities is 4/5 bilaterally. Upper extremities are 5/5 bilaterally with adequate range of motion.,SKIN: Warm and dry. No obvious rashes, lesions, or ulcerations. ,NEUROLOGIC: Alert, not oriented to place and date. His speech is clear. There are no focal motor or sensory deficits.,PSYCHIATRIC: Talkative, pleasant affect with limited impulse control, severe short-term memory loss.,LABORATORY DATA:, Blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. BUN 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,DIAGNOSTIC DATA:, St. Jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and VVIR mode, implant date 08/2000, 100% paced in right ventricle, battery status is ERI. A 12-lead ECG 12/15/08 shows 100% paced rhythm with rate of 80. No Q waves at the baseline of atrial fibrillation. Last measured ejection fraction 40% 12/08 with no significant decompensation.,IMPRESSION/PLAN:,1. Sick sinus syndrome.,2. Atrial fibrillation.,3. Pacemaker dependent.,4. Mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. Pacemaker battery end of life requiring exchange.,6. Dementia of Alzheimer's disease with short and long term memory dysfunction. The dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. Dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. I explain the patient and reimplantation with any device in the surgical suite. He will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. Admit the patient after surgery for postoperative care and monitoring. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PROCEDURES,1. Left heart catheterization.,2. Coronary angiography.,3. Left ventriculogram.,PREPROCEDURE DIAGNOSIS:, Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,INDICATION: ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:, After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory. He was prepped and draped in the usual sterile manner. The right inguinal area was anesthetized with 2% Xylocaine. A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique. JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively. Coronary angiographies were performed. These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle. Left ventriculography was performed. The patient tolerated the procedure well. At the end of the procedure, all catheters and sheaths were removed. The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE: ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL. Ejection fraction was calculated to be 69%. There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex. The LAD is small in caliber. In addition, there is a long bifurcating small-caliber diagonal branch noted. LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch. LCX and its branches are free of disease.,RCA:, RCA is a dominant small-caliber vessel with long small-caliber PDA branch. RCA and its branches are free of disease.,IMPRESSION,1. No angiographic evidence of coronary artery disease.,2. Normal left ventricular systolic function.,3. Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain. ### Label: Cardiovascular / Pulmonary ### Response:

Cardiovascular / Pulmonary

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle. ### Label: Podiatry ### Response:

Podiatry

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: INDICATIONS FOR PROCEDURE:, Persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,PREMEDICATION:,1. Demerol 50 mg.,2. Phenergan 25 mg.,3. Atropine 0.6 mg IM.,4. Nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of Versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,PROCEDURE DETAILS:, With the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the Olympus bronchoscope was introduced through the right naris to the level of the cords. The cords move normally with phonation and ventilation. Two times 2 mL of 1% lidocaine were instilled on the cords and the cords were traversed. Further 2 mL of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. Scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. Upper lobe and lingula were unremarkable. There appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. This had been a change from the prior bronchoscopy of unclear significance. Distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. The scope was wedged in the left lower lobe posterior basal segment and a BAL was done with good returns, which were faintly hemorrhagic. The scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. The scope was withdrawn. The patient's saturation remained 93%-95% throughout the procedure. Blood pressure was 103/62. Heart rate at the end of the procedure was about 100. The patient tolerated the procedure well. Samples were sent as follows. Washings for AFB, Gram-stain Nocardia, Aspergillus, and routine culture. Lavage for AFB, Gram-stain Nocardia, Aspergillus, cell count with differential, cytology, viral mycoplasma, and Chlamydia culture, GMS staining, RSV by antigen, and Legionella and Chlamydia culture. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:, Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:, The patient was brought to the operating room and placed on the operating table in a supine position. After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg. The left foot was then prepped, scrubbed, and draped in normal sterile technique. The left ankle tourniquet was inflated. Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe. The incision was deepened through subcutaneous tissues. All the bleeders were identified, cut, clamped, and cauterized. The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint. All the tendinous neurovascular structures were identified and retracted from the site to be preserved. Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal. The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion. A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint. The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw. The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal. The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation. The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal. Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction. The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique. The wires were removed. Fixation on the table was found to be excellent. Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical. The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw. The area was copiously flushed with saline. The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues. The incision site was reinforced with Steri-Strips. At this time, the patient's left ankle tourniquet was deflated. The time was 45 minutes. Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff. The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage. The patient's left foot was then placed in a surgical shoe. The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. The patient was given pain medication and instructions on how to control her postoperative course. The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment. ### Label: Orthopedic ### Response:

Orthopedic

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:, General with an interscalene block.,COMPLICATIONS:, None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION: ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder. The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture. Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted. Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result. The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks. Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1. Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered. The clavicular head was noted to be intact. There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2. Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3. A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site. Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area. His right shoulder was identified, marked his appropriate surgical site after verification with the patient. He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team. He then received prophylactic antibiotics. A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment. At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes. The right upper extremity was then prepped and draped in the usual sterile fashion. Preoperative markings were still visible at this point. A deltopectoral incision was made utilizing the inferior portion. Dissection was carried down. The deltoid was retracted laterally. The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion. There was a small cuff of tissue left on the proximal humerus associated with the clavicular head. Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion. This allowed reapproximation of the retracted tendon to the tendon stump. At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site. At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone. For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded. The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair. At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation. Aggressive external rotation was not performed. The wound was then copiously irrigated. The cephalic vein was not injured during the case. The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips. Sterile dressing was then placed. Anesthesia was then performed, interscalene block. The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days. We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: PREOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1. Surgical absence of left nipple areola with personal history of breast cancer.,2. Breast asymmetry.,PROCEDURE,1. Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2. Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure. The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region. This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease. The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion. The area was dressed with antibiotic ointment and then a Peri-Pad. The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes. Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex. Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized. Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple. At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple. When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft. At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola. At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic. The areolar skin graft was pie crusted. Then, at this point, the area of areola was dressed with silicone gel sheeting. A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position. Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made. The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out. When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision. Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola. The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: SUBJECTIVE:, The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.,OBJECTIVE:, The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. He has lost a total of 34-1/2 pounds. I praised this. I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop. I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:, The patient is losing weight at an acceptable rate. He needs to continue keeping a food diary and his regular physical activity.,PLAN:, The patient plans to see Dr. XYZ at the end of May 2005. I recommended that they ask Dr. XYZ what weight he would like for the patient to be at. Follow up will be with me June 13, 2005. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: GENERAL: , Vital signs and temperature as documented in nursing notes. The patient appears stated age and is adequately developed.,EYES:, Pupils are equal, round, reactive to light and accommodation. Lids and conjunctivae reveal no gross abnormality.,ENT: ,Hearing appears adequate. No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline. Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:, The patient has normal and symmetric respiratory effort. Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender. Bowel sounds are active. No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL: ,The patient is ambulatory with normal and symmetric gait. There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions. Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:, Mental status, judgment and affect are grossly intact and normal for age. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: 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 ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: CHIEF COMPLAINT:, Altered mental status.,HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available.,PAST MEDICAL HISTORY:, Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.,PAST SURGICAL HISTORY:, Unknown.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, The patient denies smoking and drinking.,MEDICATIONS:, Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily.,ALLERGIES:, UNKNOWN.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84.,GENERAL: Well-developed, well-nourished male in no acute distress.,HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal.,NECK: No JVD. No thyromegaly.,CARDIOVASCULAR: Irregular rhythm. No lower extremity edema.,RESPIRATORY: Clear to auscultation bilaterally with normal effort.,ABDOMEN: Nontender. Nondistended. Bowel sounds are positive.,MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout.,NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout.,LABORATORY DATA:, By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.,Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09.,ASSESSMENT AND PLAN:,1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.,2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.,3. Hypertension. I will continue his home medications and add clonidine as needed.,4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.,5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.,6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: CC:, Left third digit numbness and wrist pain.,HX: ,This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.,SHX/FHX:, 1-2 ppd Cigarettes. Married. Off work for two weeks due to complaints.,EXAM: ,Vital signs unremarkable.,MS:, A & O to person, place, time. Fluent speech without dysarthria.,CN II-XII: ,Unremarkable,MOTOR:, 5/5 throughout, including intrinsic muscles of hands. No atrophy or abnormal muscle tone.,SENSORY:, Decreased PP in third digit of left hand only (palmar and dorsal sides).,STATION/GAIT/COORD:, Unremarkable.,REFLEXES: ,1+ throughout, plantar responses were downgoing bilaterally.,GEN EXAM: ,Unremarkable.,Tinel's manuever elicited pain and numbness on the left. Phalens sign present on the left.,CLINICAL IMPRESSION: ,Left Carpal Tunnel Syndrome,EMG/NCV: ,Unremarkable.,MRI C-spine, 12/1/92: Congenitally small spinal canal is present. Superimposed on this is mild spondylosis and disc bulge at C6-7, C5-6, C4-5, and C3-4. There is moderate central spinal stenosis at C3-4. Intervertebral foramina at these levels appear widely patent.,COURSE:, The MRI findings did not correlate with the clinical findings and history. The patient was placed on Elavil and was subsequently lost to follow-up. ### Label: Radiology ### Response:

Radiology

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

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: Her axial back pain is greatly improved, but not completely eradicated. There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:, Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:, Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired. Denies tobacco or ethanol use.,FAMILY HISTORY:, Father died of mesothelioma. Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia. Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:, Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN: ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome. Her lumbar facet joints were denervated approximately 6 months ago. The denervation procedure helped her axial back pain approximately 40% when standing. With extension and rotation it helped her axial back pain approximately 70%. She is now able to swing a golf club. She was unable to swing a golf club due to the rotational movements before her rhizotomy. She is currently playing golf. Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d. We will follow her up in 1 month's time., ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: S -, An 84-year-old diabetic female, 5'7-1/2" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.,O - ,Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.,A - ,1. Painful feet., ### Label: SOAP / Chart / Progress Notes ### Response:

SOAP / Chart / Progress Notes

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: 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: ENT - Otolaryngology ### Response:

ENT - Otolaryngology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: OPERATIONS/PROCEDURES,1. Insertion of right internal jugular Tessio catheter.,2. Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The right neck, chest and left arm were prepped and draped in a sterile fashion. A small incision was made at the top of the anterior jugular triangle in the right neck. Through this small incision, the right internal jugular vein was punctured and a guidewire was placed. It was punctured a 2nd time, and a 2nd guidewire was placed. The Tessio catheters were assembled. They were measured for length. Counter-incisions were made on the right chest. They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs. They were flushed with saline. A suture was placed through the guidewire, and the guidewire and dilator were removed. The arterial catheter was then placed through this, and the tear-away introducer was removed. The catheter aspirated and bled easily. It was flushed with saline and capped. This was repeated with the venous line. It also aspirated easily and was flushed with saline and capped. The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon. Dressings were applied. An incision was then made at the left wrist. The basilic vein was dissected free, as was the radial artery. Heparin was given, 50 mg. The radial artery was clamped proximally and distally with a bulldog. It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed. The vein was clipped distally, divided and spatulated for anastomosis. It was sutured to the radial artery with a running 7-0 Prolene suture. The clamps were removed. Good flow was noted through the artery. Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin. The patient tolerated the procedure well. ### Label: Cardiovascular / Pulmonary ### Response:

Cardiovascular / Pulmonary

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: HISTORY: ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke. The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study. The patient stated that the results of that modified revealed aspiration with thin liquids only. He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids. A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips. Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow. Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid. Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow. The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule. The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids. The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food. The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling. Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation. The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid. No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1. The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2. The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3. The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4. The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient. I look forward to working with him in the outpatient setting to improve his swallowing function and safety. Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety. ### Label: Gastroenterology ### Response:

Gastroenterology

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: POSTOPERATIVE DIAGNOSIS:, Mild tracheobronchitis with history of granulomatous disease and TB, rule out active TB/miliary TB.,PROCEDURE PERFORMED:, Flexible fiberoptic bronchoscopy diagnostic with:,a. Right middle lobe bronchoalveolar lavage.,b. Right upper lobe bronchoalveolar lavage.,c. Right lower lobe transbronchial biopsies.,COMPLICATIONS:, None.,Samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,INDICATION: ,The patient with a history of TB and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,PROCEDURE:, After obtaining an informed consent, the patient was brought to the Bronchoscopy Suite with appropriate isolation related to ______ precautions. The patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure. 2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved. Topical anesthesia with 10 cc of 4% Xylocaine was applied to the right nares and oropharynx. Subsequent to this, the patient was premedicated with 50 mg of Demerol and then Versed 1 mg sequentially for a total of 2 mg. With this, adequate consciousness sedation was achieved. 3 cc of 4% viscous Xylocaine was applied to the right nares. The bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,The oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,There was normal vocal cord motion without masses or lesions. Additional topical anesthesia with 2% Xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc. The bronchoscope was then advanced through the larynx into the trachea. The trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions. These were suctioned clear. The bronchoscope was then advanced through the carina, which was sharp. Then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized. There was mild tracheobronchitis with mild friability throughout. There was modest amounts of white secretion. There were no other findings including evidence of mass, anatomic distortions, or hemorrhage. The bronchoscope was subsequently withdrawn and advanced into the right mainstem. Again, each segment and subsegment was well visualized. The right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments. No specific masses or other lesions were identified throughout the tracheobronchial tree on the right. There was mild tracheal bronchitis with friability. Upon coughing, there was punctate hemorrhage. The bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe. These again had no other anatomic lesions identified. The bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained. The bronchoscope was withdrawn and the area was suctioned clear. The bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed. Samples were taken and the bronchoscope was removed suctioned the area clear. The bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe. Minimal hemorrhage was identified and suctioned clear without difficulty. The bronchoscope was then withdrawn to the mainstem. The area was suctioned clear. Fluoroscopy revealed no evidence of pneumothorax. The bronchoscope was then withdrawn. The patient tolerated the procedure well without evidence of desaturation or complications. ### Label: Surgery ### Response:

Surgery

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: FAMILY HISTORY AND SOCIAL HISTORY:, Reviewed and remained unchanged.,MEDICATIONS:, List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:, She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS: ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain. Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs: Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General: She was a pleasant person in no acute distress.,HEENT: Normocephalic and atraumatic. No dry mouth. No palpable cervical lymph nodes. Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:, Remained unchanged.,Mental Status: Normal.,Cranial Nerves: Mild decrease in the left nasolabial fold.,Motor: There was mild increased tone in the left upper extremity. Deltoids showed 5-/5. The rest showed full strength. Hip flexion again was 5-/5 on the left. The rest showed full strength.,Reflexes: Reflexes were hypoactive and symmetrical.,Gait: She was mildly abnormal. No ataxia noted. Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement. She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes. She will continue to follow with endocrinology for diabetes and thyroid problems. I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery. I will see her back in about four months or sooner if needed. ### Label: Consult - History and Phy. ### Response:

Consult - History and Phy.

Write a response that appropriately completes the request. ### Instruction: Classify the following document as one of the following medical specialties: Cardiovascular / Pulmonary Dermatology Surgery IME-QME-Work Comp etc. General Medicine Orthopedic Gastroenterology Pain Management Consult - History and Phy. Radiology Hematology - Oncology Neurology Nephrology Podiatry Office Notes Rheumatology Neurosurgery Endocrinology Discharge Summary Bariatrics SOAP / Chart / Progress Notes ENT - Otolaryngology Ophthalmology Letters Cosmetic / Plastic Surgery Dentistry Physical Medicine - Rehab Psychiatry / Psychology Autopsy Sleep Medicine Speech - Language Allergy / Immunology Lab Medicine - Pathology Chiropractic SCARF type Document: ### Document: Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2. CAD/angina. See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed., ### Label: Gastroenterology ### Response:

Gastroenterology