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: TITLE OF PROCEDURE: , Insertion of Port-A-Cath via left subclavian vein using fluoroscopy.,PREOPERATIVE DIAGNOSIS: ,Metastatic renal cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Metastatic renal cell carcinoma.,PROCEDURE IN DETAIL:, This is a 49-year-old gentleman was referred by Dr. A. The patient underwent a left nephrectomy for renal cell carcinoma in 1999 in Philadelphia. He has developed recurrence with metastases to the lung and to bone.,The patient is on dialysis via a right internal jugular PermCath that was placed elsewhere.,In the operating room under monitored anesthesia care with intravenous sedation, the patient was prepped and draped suitably. Lidocaine 1% with epinephrine was used for local anesthesia and the left subclavian vein was punctured at the first pass without difficulty. A J-wire was guided into place under fluoroscopic control. A 7.2-French vortex titanium Port-A-Cath was now anchored in the subcutaneous pocket made just below using 3-0 Prolene. The attached catheter tunneled, cut to the appropriate length and placed through the sheath that was then peeled away. Fluoroscopy showed good catheter disposition in the superior vena cava. The catheter was accessed with a butterfly Huber needle, blood was aspirated easily and the system was then flushed using heparinized saline. The pocket was irrigated using antibiotic saline and closed with absorbable suture. The port was left accessed with the butterfly needle after dressings were applied and the patient is to report to Dr. A's office later today for the commencement of chemotherapy. There were no 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: PROCEDURE: ,Caudal epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS: , See nurse's records.,PROCEDURE DETAILS: , INT was placed. The patient was in the prone position. The back was prepped with Betadine. Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus. A 18-gauge Tuohy needle was then placed into the epidural space. There were no complications from this (no blood or CSF). After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected. Neosporin and band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to outpatient recovery in stable condition. ### Label: Pain Management ### Response:

Pain Management

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:, History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES: ,1. History of perforated sigmoid diverticuli with Hartmann's procedure.,2. Massive adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions and removal.,3. Reversal of Hartmann's colostomy.,4. Flexible sigmoidoscopy.,5. Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula. Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE: ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion. A cystoscope was introduced into the patient's urethra and to the bladder. Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra. The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley. At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline. Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall. Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall. Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis. At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats. The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made. First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well. Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound. Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired. The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied. Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum. The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it. The EEA was then fired. Once it was fired and was removed, the pelvis was filled with fluid. Immediately both doughnuts were ____ from the anastomosis. A Doyen was placed in both the anastomosis. Colonoscope was introduced. No bubble or air was seen coming from the anastomosis. There was no evidence of bleeding. Pictures of the anastomosis were taken. The scope then was removed from the patient's rectum. Copious amount of irrigation was used within the peritoneal cavity. Immediately at this point, all complete sponge and instrument count was performed. First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture. The peritoneum was closed with running #2-0 Vicryl suture. Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle. Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well. The patient did tolerate the procedure well and will be followed during the hospitalization. The left ureteral stent was removed at the end of the procedure. _____ were performed. Lysis of adhesions were performed. Reversal of colostomy and EEA anastomosis #29 Ethicon. ### 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: MEDICAL DIAGNOSIS:, Strokes.,SPEECH AND LANGUAGE THERAPY DIAGNOSIS: ,Global aphasia.,SUBJECTIVE: ,The patient is a 44-year-old female who is referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy, status post stroke. The patient's sister-in-law was present throughout this assessment and provided all the patient's previous medical history. Based on the sister-in-law's report, the patient had a stroke on 09/19/08. The patient spent 6 weeks at XY Medical Center, where she was subsequently transferred to XYZ for therapy for approximately 3 weeks. ABCD brought the patient to home the Monday before Thanksgiving, because they were not satisfied with the care the patient was receiving at a skilled nursing facility in Tucson. The patient's previous medical history includes a long history of illegal drug use to include cocaine, crystal methamphetamine, and marijuana. In March of 2008, the patient had some type of potassium issue and she was hospitalized at that time. Prior to the stroke, the patient was not working and ABCD reported that she believes the patient completed the ninth grade, but she did not graduate from high school. During the case history, I did pose several questions to the patient, but her response was often "no." She was very emotional during this evaluation and crying occurred multiple times.,OBJECTIVE: ,To evaluate the patient's overall communication ability, a Western Aphasia Battery was completed. Also tests were not done due to time constraint and the patient's severe difficulty and emotional state. Speech automatic tests were also completed to determine if the patient had any functional speech.,ASSESSMENT:, Based on the results of the Weston aphasia battery, the patient's deficits most closely resemble global aphasia. On the spontaneous speech subtest, the patient responded "no" to all questions asked except for how are you today where she gave a thumbs-up. She provided no responses to picture description task and it is unclear if the patient was unable to follow the direction or if she was unable to see the picture clearly. The patient's sister-in-law did state that the patient wore glasses, but she currently does not have them and she did not know the extent the patient's visual deficit.,On the auditory verbal comprehension portion of the Western Aphasia Battery, the patient answered "no" to all "yes/no" questions. The auditory word recognition subtest, the patient had 5 out of 60 responses correct. With the sequential command, she had 10 out of 80 corrects. She was able to shut her eyes, point to the window, and point to the pen after directions. With repetition subtest, she repeated bed correctly, but no other stimuli. At this time, the patient became very emotional and repeatedly stated "I can't". During the naming subtest of the Western Aphasia Battery, the patient's responses contained numerous paraphasias and her speech was often unintelligible due to jargon. The word fluency test was not administered and the patient scored 2 out of 10 on the sentence completion task and 0 out of 10 on the responsive speech. In regards to speech automatics, the patient is able to count from 1 to 9 accurately; however, stated 7 instead of 10 at the end of the task. She is not able to state the days of the week or months in the year or her name at this time. She cannot identify the day on calendar and was unable to verbally state the date or month.,DIAGNOSTIC IMPRESSION: ,The patient's communication deficits most closely resemble global aphasia where she has difficulty with both receptive as well as expressive communication. She does perseverate and is very emotional due to probable frustration. Outpatient skilled speech therapy is recommended to improve the patient's functional communication skills.,PATIENT GOAL: , Her sister-in-law stated that they would like to improve upon the patient's speech to allow her to communicate more easily at home.,PLAN OF CARE: , Outpatient skilled speech therapy two times a week for the next 12 weeks. Therapy to include aphasia treatment and home activities.,SHORT-TERM GOALS (8 WEEKS):,1. The patient will answer simple "yes/no" questions with greater than 90% accuracy with minimal cueing.,2. The patient will be able to complete speech automatic tasks with greater than 80% accuracy without models or cueing.,3. The patient will be able to complete simple sentence completion and/or phrase completion with greater than 80% accuracy with minimal cueing.,4. The patient will be able to follow simple one-step commands with greater than 80% accuracy with minimal cueing.,5. The patient will be able to name 10 basic everyday objects with greater than 80% accuracy with minimal cueing.,SHORT-TERM GOALS (12 WEEKS):, Functional communication abilities to allow the patient to express her basic wants and needs. ### 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 APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit. Height is ?? feet ?? inches. Weight is ?? pounds. This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:, The pupils were equal, round and reactive to light. Extraocular movements are intact. Sclera are nonicteric. Ears, nose, mouth and throat - Externally the ears and nose are normal. The mucous membranes are moist and midline.,NECK: ,The neck is supple without masses. No thyromegaly, no carotid bruits, no adenopathy.,LUNGS: ,There is a normal respiratory effort. Bilateral breath sounds are clear. No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location. S1 and S2 are normal. No rubs, murmurs or gallops. A regular rate and rhythm. There are no abdominal aortic bruits. The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS: ,The breasts show no masses or tenderness. No axillary adenopathy.,ABDOMEN:, The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:, Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact. Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three. Judgment and insight are good. Affect is appropriate. ### 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: REPORT: ,This is an 18-channel recording obtained using the standard scalp and referential electrodes observing the 10/20 international system. The patient was reported to be cooperative and was awake throughout the recording.,CLINICAL NOTE: ,This is a 51-year-old male, who is being evaluated for dizziness. Spontaneous activity is fairly well organized, characterized by low-to-medium voltage waves of about 8 to 9 Hz seen mainly from the posterior head region. Intermixed with it is a moderate amount of low voltage fast activity seen from the anterior head region.,Eye opening caused a bilateral symmetrical block on the first run. In addition to the above description, movement of muscle and other artifacts are seen.,On subsequent run, no additional findings were seen.,During subsequent run, again no additional findings were seen.,Hyperventilation was omitted.,Photic stimulation was performed, but no clear-cut photic driving was seen.,EKG was monitored during this recording and it showed normal sinus rhythm when monitored.,IMPRESSION: ,This record is essentially within normal limits. Clinical correlation is recommended. ### 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: PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY: ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks. The patient is also diabetic. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia. The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored. There was no evidence of any peritoneal studding or masses. The abdomen was otherwise within normal limits. The gallbladder was easily visualized. There was an intrahepatic gallbladder. There was no evidence of any inflammatory change.,PROCEDURE:, After informed written consent, the risks and benefits of the procedure were explained to the patient. The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion. Next, an infraumbilical incision was made with a #10 scalpel. The skin was elevated with towel clips and a Veress needle was inserted. The abdomen was then insufflated to 15 mmHg of pressure. The Veress needle was removed and a #10 blade trocar was inserted without difficulty. The laparoscope was then inserted through this #10 port and the abdomen was explored. There was no evidence of any peritoneal studding. The peritoneum was smooth. The gallbladder was intrahepatic somewhat. No evidence of any inflammatory change. There were no other abnormalities noted in the abdomen. Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty. The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization. The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder. Using a curved dissector, the cystic duct was identified and freed up circumferentially. Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct. The cystic artery was transected in similar fashion. Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip. It was done without difficulty. The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology. Hemostasis was maintained using electrobovie cautery. The liver bed was then copiously irrigated and aspirated. All the fluid and air was then aspirated and then all ports were removed under direct visualization. The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle. The skin was closed with a running subcuticular #4-0 undyed Vicryl. 0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied. The patient tolerated the procedure well and was transferred to Recovery in stable 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: REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality. The left ventricle was normal in size and dimensions with normal LV function. Ejection fraction was 50% to 55%. Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm. Left atrium is enlarged, measuring 4.42 cm. Right-sided chambers are normal in size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification. Fibrocalcific valve leaflets noted with adequate excursion. Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation. Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis. There is also mitral stenosis.,IMPRESSION:,1. Concentric hypertrophy of the left ventricle with left ventricular function.,2. Moderate mitral regurgitation.,3. Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area. ### Label: 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: PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type. ### Label: 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: Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation. ### 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: DISCHARGE DIAGNOSES:,1. Chest pain. The patient ruled out for myocardial infarction on serial troponins. Result of nuclear stress test is pending.,2. Elevated liver enzymes, etiology uncertain for an outpatient followup.,3. Acid reflux disease.,TEST DONE: , Nuclear stress test, results of which are pending.,HOSPITAL COURSE: , This 32-year-old with family history of premature coronary artery disease came in for evaluation of recurrent chest pain, O2 saturation at 94% with both atypical and typical features of ischemia. The patient ruled out for myocardial infarction with serial troponins. Nuclear stress test has been done, results of which are pending. The patient is stable to be discharged pending the results of nuclear stress test and cardiologist's recommendations. He will follow up with cardiologist, Dr. X, in two weeks and with his primary physician in two to four weeks. Discharge medications will depend on results of nuclear stress test. ### 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: REASON FOR CONSULT: , A patient with non-Q-wave myocardial infarction.,HISTORY OF PRESENT ILLNESS: , The patient is a pleasant 52-year-old gentleman with a history of diabetes mellitus, hypertension, and renal failure, on dialysis, who presented with emesis, dizziness, and nausea for the last few weeks. The patient reports having worsening emesis and emesis a few times. No definite chest pains. The patient is breathing okay. The patient denies orthopnea or PND.,PAST MEDICAL HISTORY:,1. Diabetes mellitus.,2. Hypertension.,3. Renal failure, on dialysis.,MEDICATIONS:, Aspirin, Coreg, doxazosin, insulin, metoclopramide, simvastatin, and Starlix.,ALLERGIES: ,NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies tobacco, alcohol or drug use.,FAMILY HISTORY: , Negative for early atherosclerotic heart disease.,REVIEW OF SYSTEMS: , General: The patient denies fever or chills. Pulmonary: The patient denies hemoptysis. Cardiovascular: Refer to HPI. GI: The patient denies hematemesis or melena. The rest of systems review is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 71, blood pressure 120/70, and respiratory rate 18.,GENERAL: A well-nourished, well-developed male in no acute distress.,HEENT: Normocephalic, atraumatic. Pupils seem to be equal, round, and reactive. Extraocular muscles are full, but the patient has left eye ptosis.,NECK: Supple without JVD or lymphadenopathy.,LUNGS: Clear to auscultation bilaterally.,CARDIOVASCULAR: PMI is displaced 0.5 cm lateral to the midclavicular line. Regular rate and rhythm, S1, S2. No definite S3, 2/6 holosystolic murmur at the apex radiating to the axilla.,ABDOMEN: Positive bowel sounds, nondistended and nontender. No hepatosplenomegaly.,EXTREMITIES: Trace pedal edema.,EKG shows atrial fibrillation with rapid ventricular response at 164 with old anteroseptal myocardial infarction and old inferior wall myocardial infarction. Subsequent EKG in sinus rhythm shows sinus rhythm with old inferior wall myocardial infarction and probable anteroseptal myocardial infarction with Q-waves in V1, V2, and up to V3.,LABORATORY EXAM: , WBC 28,800, hemoglobin 13.6, hematocrit 40, and platelets 266,000. PT 11.3, INR 1.1, and PTT 24.1. Sodium 126, potassium 4.3, chloride 86, CO2 26, glucose 371, BUN 80, and creatinine 8.4. CK was 261, then 315, and then 529 with CK-MB of 8.06, then 8.69, and then 24.6. Troponin was 0.051, then 0.46, and then 19.8 this morning.,IMPRESSION:,1. Paroxysmal atrial fibrillation. The heart rate was slowed down with IV Cardizem, the patient converted to sinus rhythm. The patient is currently in sinus rhythm.,2. Emesis. The etiology is unclear. The patient reports that the emesis is better. The patient is just having some nausea.,3. Non-Q-wave myocardial infarction. EKG shows atrial fibrillation with old anteroseptal myocardial infarction and old inferior wall myocardial infarction.,4. Diabetes mellitus.,5. Renal failure.,6. Hypertension.,7. Hypercholesterolemia.,PLAN:,1. We will start amiodarone to keep from going back into atrial fibrillation.,2. Echocardiogram.,3. Aspirin and IV heparin.,4. Serial CK-MB and troponin.,5. Cardiac catheterization, possible percutaneous coronary intervention. The risks, benefits, and alternatives were explained to the patient through a translator. The patient understands and wishes to proceed.,6. IV Integrilin. ### 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 CODES: 64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS: Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA: MAC.,COMPLICATIONS: None.,DESCRIPTION OF TECHNIQUE: Informed consent was obtained from the patient's mom. The patient was brought to minor procedures and sedated per their protocol. The patient was positioned lying supine. Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation. Approximately 4 mL of 5% phenol was injected in this location bilaterally. Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus. Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation. Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally. Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL. After injections were performed, bilateral short leg fiberglass casts were applied. The patient tolerated the procedure well and no complications were encountered. ### 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: PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications. ### 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: SUMMARY: ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia. She has had an uneventful postoperative night. She put out 1175 mL of urine since surgery. Her incision looks good. IV site and extremities are unremarkable.,LABORATORY DATA: ,Her calcium level was 7.5 this morning. She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:, I will heparin lock her IV, advance her diet, and ambulate her. I have asked her to increase her prednisone when she goes home. She will double her regular dose for the next five days. I will advance her diet. I will continue to monitor her calcium levels throughout the day. If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow. She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill. Her final calcium dosage will be determined prior to discharge. I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems. ### 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:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:, Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:, The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery. The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth. After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1. Methadone.,2. Beta-blocker.,3. Xanax.,4. Norco.,5. Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present. The patient was prepped and draped in sterile fashion. Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible. Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered. Extraction sites were thoroughly curettaged and irrigated. Bony undercuts were removed then smoothed with rongeurs and bone saw. After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures. Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions. Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged. Wound was closed in continuous fashion 3-0 chromic. After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control. Total of 8 mL were used. Throat pack was subsequently removed. Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery. The patient would be placed in 23-hour observation. ### Label: Dentistry ### Response:

Dentistry

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: PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:, Basal Cell CA.,LOCATION: ,Medial right inferior helix.,PREOP SIZE:, 1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results. ### 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: REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future. ### 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: DIAGNOSIS:, Synovitis/anterior cruciate ligament tear of the left knee.,HISTORY: , The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only.,PAST MEDICAL HISTORY: , Past medical history is unremarkable.,MEDICAL IMAGING: , Medical imaging is significant for x-rays and MRIs. The report was available at the time of the evaluation. The patient reports abnormal posterior horn of medial meniscus consistent with knee degenerative change and possibly tears.,MEDICATIONS:,1. Tramadol.,2. Diclofenac.,3. Advil.,4. Tylenol.,SUBJECTIVE: , The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.,FUNCTIONAL ACTIVITIES AND HOBBIES: ,Functional activities and hobbies that are currently limited include any work as the patient is currently unemployed and is looking for a job; however, his primary skills are of a laborer and a street broker for new homes.,OBJECTIVE: ,Upon observation, the patient is ambulating with a significant antalgic gait pattern. However, he is not using any assistive device. The knee brace was corrected and the patient and his wife demonstrated understanding and knowledge of how to place the knee brace on correctly.,ACTIVE RANGE OF MOTION: , Active range of motion of the left knee is 0 to 105 degrees with pain during range of motion. Right knee active range of motion is 0 to 126 degrees.,STRENGTH: ,Strength is 3/5 for left knee, 4+/5 for right knee. The patient denies any pain upon light and deep palpation at the knee joints. There is no evidence of temperature change, increased swelling or any discoloration at the left knee joint. The patient does not appear to have instability at this time with formal tests at the left knee joint.,SPECIAL TESTS: ,The patient performed a six-minute walk test. He was able to complete 600 feet; however, had to stop this test at approximately five minutes, secondary to significant increase in pain.,ASSESSMENT:, The patient would benefit from skilled physical therapy intervention in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to perform functional activities and work tasks.,5. Decreased ambulation tolerance.,SHORT-TERM GOALS TO BE COMPLETED IN THREE WEEKS:,1. Patient will demonstrate independence with the home exercise program.,2. Patient will report maximum pain of 2/10 on a Pain Analog Scale within a 24-hour period.,3. The patient will demonstrate left knee active range of motion, 0 to 120 degrees, without significant increase in pain during motion.,4. The patient will demonstrate 4/5 strength for the left knee.,5. The patient will complete 800 feet in a six-minute walk test without significant increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN SIX WEEKS:,1. The patient will demonstrate bilateral knee active range of motion, 0 to 130 degrees.,2. The patient will demonstrate 5/5 lower extremity strength bilaterally without significant increase in pain.,3. Patient will complete 1000 feet in a six-minute walk test without increase in pain and tolerate full completion of the six minutes.,4. The patient will improve confidence with ability to perform work activity, when the situation improves and resolves.,PROGNOSIS: ,Prognosis is good for above-stated goals, with compliance to a home exercise program and treatment.,SESSION PLAN: , The patient to be seen two to three times a week for six weeks for the following:,1. Therapeutic exercise with home exercise program. ### Label: Physical Medicine - Rehab ### Response:

Physical Medicine - Rehab

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: Thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. On December 5, 2008, Mr. XXXX did undergo a total knee replacement arthroplasty performed by Dr. X.,Thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,At the present time, he does complain of significant pain and swelling as related to the right knee. He is unable to crawl and/or kneel. He does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill. Stairs are a significant problem. His pain is a 5 to 6 on a scale of 1 to 10.,He is better when he is resting, sitting, propped up, and utilizing his ice. He is much worse when he is doing any type of physical activity.,He has denied having any previous history of similar problems.,CURRENT MEDICATIONS: ,Over-the-counter pain medication.,ALLERGIES: , NKA.,SURGERIES: , Numerous surgeries as related to the right lower extremity.,SOCIAL HISTORY: , He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.,PHYSICAL EXAMINATION: ,On examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds. He does not appear to be in distress at this time. One could appreciate 1-2/4 intraarticular effusion. The range of motion is 0 to a 110 degrees of flexion. I could not appreciate any evidence of instability medial, lateral, anterior or posterior. Crepitus is noted with regards to range of motion testing. His strength is 4 to 5 as related to the quadriceps and hamstring.,There is atrophy as related to the right thigh. The patient is able to stand from a seated position and sit from a standing position without difficulty.,RECORDS REVIEW:,1. First report of injury.,2. July 17, 2002, x-rays of the right knee were negative.,3. Notes of the Medina General Hospital Occupational Health, Steven Rodgers, M.D.,4. August 5, 2002, an MRI scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial ### Label: 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: BLEPHAROPLASTY,The patient was prepped and draped. The upper lid skin was marked out in a lazy S fashion, and the redundant skin marked out with a Green forceps. Then the upper lids were injected with 2% Xylocaine and 1:100,000 epinephrine and 1 mL of Wydase per 20 mL of solution.,The upper lid skin was then excised within the markings. Gentle pressure was placed on the upper eyelids, and the fat in each of the compartments was teased out using a scissor and cotton applicator; and then the fat was cross clamped, cut, and the clamp cauterized. This was done in the all compartments of the middle and medial compartments of the upper eyelid, and then the skin sutured with interrupted 6-0 nylon sutures. The first suture was placed in the lower eyelid skin picking up the periorbital muscle and then the upper portion of the tarsus and then the upper lid skin. This created a significant crisp, supratarsal fold. The upper lid skin was closed in this fashion, and then attention was turned to the lower lid.,An incision was made under the lash line and slightly onto the lateral canthus. The #15 blade was used to delineate the plane in the lateral portion of the incision, and then using a scissor the skin was cut at the marking. Then the skin muscle flap was elevated with sharp dissection. The fat was located and using a scissor the three eyelid compartments were opened. Fat was teased out, cross clamped, the fat removed, and then the clamp cauterized. Once this was done the skin was tailored to the lower lid incision site with mouth open and eyes in upward gaze, and then the excess skin removed. The suture line was sutured with interrupted 6-0 silk sutures. Once this was done the procedure was finished.,The patient left the OR in satisfactory condition. The patient was given 50 mg of Demerol IM with 25 mg of Phenergan. ### Label: Cosmetic / Plastic Surgery ### Response:

Cosmetic / Plastic 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 DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis. Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction. There was no evidence of either inflammation or a fistulous opening. The scope was withdrawn. A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position). Some purulent material could be expressed through the opening. There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material. Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable. In addition, scars were noted in the perianal area. The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position. The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek. There were no other abnormalities noted. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Normal colonoscopy to the terminal ileum.,2. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1. Continue antibiotics.,2. Followup with Dr. X.,3. If drainage persists, consider surgical drainage. ### 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 DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Normal colon with no evidence of bleeding.,2. Hiatal hernia.,3. Fundal gastritis with polyps.,4. Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN: ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes. She has been anemic as well with no gross evidence of blood loss. She has had a decreased appetite with weight loss greater than 20 lb over the past few months. After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids. The colonoscope was inserted into the rectum and air was insufflated. The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum. There were no polyps, masses, diverticuli, or areas of inflammation. The scope was then slowly withdrawn carefully examining all walls. Air was aspirated. Once in the rectum, the scope was retroflexed. There was no evidence of perianal disease. No source of the anemia was identified.,Attention was then taken for performing an EGD. The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx. The esophagus was easily intubated and traversed. There were no abnormalities of the esophagus. The stomach was entered and was insufflated. The scope was coursed along the greater curvature towards the antrum. Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______. It was not clear if this represents a healing ulcer or neoplasm. Several biopsies were taken. The mass was soft. The pylorus was then entered. The duodenal bulb and sweep were examined. There was no evidence of mass, ulceration, or bleeding. The scope was then brought back into the antrum and was retroflexed. In the fundus and body, there was evidence of streaking and inflammation. There were also several small sessile polyps, which were removed with biopsy forceps. Biopsy was also taken for CLO. A hiatal hernia was present as well. Air was aspirated. The scope was slowly withdrawn. The GE junction was unremarkable. The scope was fully withdrawn. The patient tolerated the procedure well and was transferred to recovery room in stable condition. She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes. We will await the biopsy reports and further recommendations will follow. ### Label: Gastroenterology ### 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 DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:, ,1. Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:, Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS:, None.,SUMMARY: ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details). Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle. After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle. These needles were removed and the patient was discharged in stable condition. ### Label: Pain Management ### Response:

Pain Management

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 EXAM: ,Left arm and hand numbness.,TECHNIQUE: , Noncontrast axial CT images of the head were obtained with 5 mm slice thickness.,FINDINGS: ,There is an approximately 5-mm shift of the midline towards the right side. Significant low attenuation is seen throughout the white matter of the right frontal, parietal, and temporal lobes. There is loss of the cortical sulci on the right side. These findings are compatible with edema. Within the right parietal lobe, a 1.8 cm, rounded, hyperintense mass is seen.,No hydrocephalus is evident.,The calvarium is intact. The visualized paranasal sinuses are clear.,IMPRESSION: ,A 5 mm midline shift to the left side secondary to severe edema of the white matter of the right frontal, parietal, and temporal lobes. A 1.8 cm high attenuation mass in the right parietal lobe is concerning for hemorrhage given its high density. A postcontrast MRI is required for further characterization of this mass. Gradient echo imaging should be obtained. ### 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: HISTORY: , The patient is a 61-year-old male patient. I was asked to evaluate this patient because of the elevated blood urea and creatinine. The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD. The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease. The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall. The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:, As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss. No history of sore throat. No history of any ascites. No history of nausea, vomiting, or diarrhea. No black stools. No history of any rash. No back pain. No leg pain. No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:, He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS: Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT: The patient is atraumatic and normocephalic. Pupils are equal and reactive to light. Extraocular muscles are intact.,NECK: Supple. No JVD and no thyromegaly.,HEART: S1 and S2 heard. No murmurs or extra sounds.,ABDOMEN: Distention of the abdomen present.,EXTREMITIES: No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34. PT, PTT, and INR is normal. Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's. Potassium is 5.3, BUN of 39, and creatinine of 1.9. Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN: ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis. The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy. We will do urine for cytology. We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels. We will send a PSA level and if needed may be a urology consult. ### Label: Nephrology ### Response:

Nephrology

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:, This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath.,HISTORY OF PRESENT ILLNESS:, I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.,She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.,Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities.,MEDICATIONS: ,1. Fosamax - 70 mg weekly.,2. Lisinopril - 20 mg daily.,3. Metformin - 850 mg daily.,4. Amlodipine - 5 mg daily.,5. Metoprolol - 150 mg twice daily.,6. Warfarin - 5 mg daily.,7. Furosemide - none.,8. Potassium - none.,9. Magnesium oxide - 200 mg daily.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time.,ASSESSMENTS: , She has chronic atrial fibrillation and heart failure now.,PROBLEMS DIAGNOSES: ,1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.,2. Heart failure and she needs more diuretic.,3. High blood pressure controlled.,4. Hyperlipidemia.,5. Diabetes mellitus type 2.,6. Nonspecific intraventricular conduction delay.,7. History of alcohol abuse.,8. Osteoporosis.,9. Normal left ventricular function.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.,Thank you for asking me to participate in her care.,MEDICATION CHANGES: , See the above. ### Label: Consult - History and Phy. ### 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: SUBJECTIVE:, The patient is a 78-year-old female with the problem of essential hypertension. She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure. She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:, Heart rate is 80 and blood pressure is 130/70. Head and neck are unremarkable. Heart sounds are normal. Abdomen is benign. Extremities are without edema.,ASSESSMENT AND PLAN:, The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past. I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc. So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4. In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup. ### 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: DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,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 COMPLAINT: ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS: ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW: ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study. ### Label: Chiropractic ### Response:

Chiropractic

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 DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. She was seen on multiple occasions at Urgent Care and in her physician's office. Initial x-ray showed some mild diffuse patchy infiltrates. She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin. Her O2 saturations drifted downward. They were less than 88% when active; at rest, varied between 88% and 92%. Decision was made because of failed outpatient treatment of pneumonia. Her medical history is significant for rheumatoid arthritis. She is on 20 mg of methotrexate every week as well as Remicade every eight weeks. Her last dose of Remicade was in the month of June. Hospital course was relatively unremarkable. CT scan was performed and no specific focal pathology was seen. Dr. X, pulmonologist was consulted. He also was uncertain as to the exact etiology, but viral etiology was most highly suspected. Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge. She was continued on Rocephin IV and azithromycin. Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status. She was instructed to finish azithromycin. She has two pills left at home. She is to follow up with Dr. X in two to three days. Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday. Methotrexate is known on some occasions to cause pneumonitis. ### 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: PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced. The abdomen was prepped and draped and ports were placed. The gallbladder was grasped and retracted. The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained. The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag. The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak. The ports were removed under direct vision with good hemostasis. The Hasson was removed. The abdomen was desufflated. The gallbladder in its endo catch bag was removed. The ports were closed. The patient tolerated the procedure well. Please see full hospital dictation. ### 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 DIAGNOSIS:, Squamous cell carcinoma of right temporal bone/middle ear space.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of right temporal bone/middle ear space.,PROCEDURE: , Right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: ,The patient was brought into the operating room, placed on the table in supine position. General endotracheal anesthesia was obtained in the usual fashion. The Neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with Betadine after shave as well as the abdomen. The neck was prepped as well. After this was performed, I made a wide ellipse of the conchal bowl with the Bovie and cutting current down through the cartilage of the conchal bowl. A wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the Bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. After this was performed, I used the Bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. The condyle was skeletonized so that it could be easily seen. The anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. The neck contents to the hyoid were dissected out. The hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. The neck contents were removed as a separate specimen. The external carotid artery was identified and tied off as it entered the parotid and tied with a Hemoclip distally for the future anastomosis. A large posterior facial vein was identified and likewise clipped for later use. I then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. It became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore I did use the router, I mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. The internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and I drilled carotid canal up until it made. I dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. Once this was dissected out, Dr. X entered the procedure for completion of the resection with the craniotomy. For details, please see his operative note.,After Dr. X had completed the resection, I then harvested the rectus free flap. A skin paddle was drawn out next to the umbilicus about 4 x 4 cm. The skin paddle was incised with the Bovie and down to the anterior rectus sheath. Sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. The sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. The skin paddle was then sutured to the fascia and muscle with interrupted 3-0 Vicryl. The anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the Bovie and reflected out of the rectus sheath to an inferior direction. The vascular pedicle could be seen entering the muscle in usual fashion. The muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large Hemoclips on each vessel. The wound was then packed with saline impregnated sponges. The rectus muscle with attached skin paddle was then transferred into the neck. The inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 Ethilon with standard microvascular technique. Ischemia time was less than 10 minutes. Likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 Ethilon as well. There was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. The wound was irrigated with copious amounts of saline. The eustachian tube was obstructed with bone wax. The muscle was then laid into position with the skin paddle underneath the conchal bowl. I removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. The wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. The subcutaneous tissues were closed with interrupted 3-0 Vicryl. The skin was closed with skin staples. There was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. The skin paddle was closed with interrupted 4-0 Prolene to the edges of the conchal bowl.,The abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 Prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. The subcutaneous tissues were closed with interrupted 2-0 Vicryl and skin was closed with skin staples. The patient was then turned over to the Neurosurgery team for awakening after the patient was appropriately awakened. The patient was then transferred to the PACU in stable condition with spontaneous respirations, having tolerated the procedure well. ### 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: SUBJECTIVE:, The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS: ,None.,ALLERGIES: ,He has no known drug allergies.,REVIEW OF SYSTEMS:, Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General: He is awake and alert, no acute distress.,Vital Signs: Blood pressure: 106/75. Temperature: 99. Pulse: 112. Weight is 54 pounds.,HEENT: His TMs are normal bilaterally. Posterior pharynx is unremarkable.,Neck: Without adenopathy or thyromegaly.,Lungs: Clear to auscultation.,Heart: Regular rate and rhythm without murmur.,Abdomen: Benign.,Skin: Turgor is intact. His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos. His platelet count on his CBC is 215.,ASSESSMENT:, Viral gastroenteritis.,PLAN:, The parents did point out to me a rash that he had on his buttock. There were some small almost pinpoint erythematous patches of papules that have a scab on them. I did not see any evidence of petechiae. Therefore, I just reassured them that this is a viral gastroenteritis. I recommended that they stop giving him juice and just go with the Gatorade and water. He is to stay away from milk products until his diarrhea and stomach upset have calmed down. We talked about BRAT diet and slowly advancing his diet as he tolerates. They have used some Kaopectate, which did not really help with the diarrhea. Otherwise follow up as needed. ### 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: SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic. Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005. She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip. An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study. Dr. XYZ had performed right intraarticular hip injection on 04/07/2005. She was last seen on 04/15/2005. At that time, she had the hip injection that helped her briefly with her pain. She is not sure whether or not she wants to proceed with hip replacement. We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today. She continues to complain of significant pain in her right hip, especially with weightbearing or with movement. She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her. She is taking Ultracet or other the generic it sounds like, up to four times daily. She states she can take this much more frequently as she still has significant pain symptoms. She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:, Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 4 inches. Weight is 149 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.,Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.,Spine: Examination shows lumbar scoliosis with surgical scar with no major tenderness. Spinal movements are limited but functional.,Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Degenerative disk disease of the right hip, symptomatic.,2. Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3. Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4. Facet and sacroiliac joint syndrome on the right, stable.,5. Post left hip arthroplasty.,6. Chronic pain syndrome.,RECOMMENDATIONS:, The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement. In the interim, her Ultracet is not quite taking care of her pain. I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day. I have written a prescription for this for 120 tablets and two refills. The patient will call for the refills when she needs them. I will plan further follow up in six months, sooner if needed. She voiced understanding and is in agreement with this plan. Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings. ### 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: CHIEF COMPLAINT: , Nausea and feeling faint.,HPI: ,The patient is a 74-year-old white female brought in by husband. The patient is a vague historian at times. She reports her appetite has been fair over the last several days. Today, she complains of some nausea. She feels weak. No other specific complaints.,REVIEW OF SYSTEMS: ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS: ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY: ,COPD and hypertension.,HABITS: ,Tobacco use, averages two cigarettes per day. Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY: ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2, pulse is 105, respirations 20, and BP 137/80. GENERAL: A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated. SKIN: Warm, dry, and good color. EYES: EOMI. PERRL. MOUTH: Clear. Mucous membranes moist. NECK: Supple. No JVD. LUNGS: Reveal faint expiratory wheeze heard in the posterior lung fields. HEART: Slightly tachycardic without murmur. ABDOMEN: Soft, positive bowel sounds, and nontender. No rebound or guarding is appreciated. BACK: No CVA tenderness. EXTREMITIES: Moves all four extremities. No pretibial edema. NEURO: Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils. Hemoglobin 10.7 and hematocrit 31.2 both are decreased. Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2. Amylase and lipase both normal. Clean catch urinalysis is unremarkable. Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7. It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD. Monitor indicates sinus tachycardia at rate 103. No ectopy.,ED COURSE: ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse. The patient was given albuterol unit dose small volume nebulizer treatment. Repeat lung exam reveals resolution of expiratory wheezing. The patient later had normal saline lock started by the nurse. She was given IV fluids of normal saline 1L wide open over approximately one hour. She was able to void urine indicating that she is well hydrated. Rectal examination was performed with female nurse in attendance. Good sphincter tone. No masses. The rectal secretions were heme negative. The patient was reassessed. She feels slightly better. Monitor now shows normal sinus rhythm, rate 81, no ectopy. Blood pressure is 136/66. The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history. Laboratory evaluation today indicates the following problems, anemia and hyponatremia. This could contribute the patient's feelings of tiredness and not feeling well. There is no evidence of rectal bleeding at this time. The patient was advised that she needs to follow up with Dr. X to further investigate these problems. The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1. Acute tiredness.,2. Anemia of unknown etiology.,3. Acute hyponatremia.,PLAN: ,The patient is advised to put salt on her food for the next week. Should be given discharge instruction sheet for anemia. Recommend follow up with personal physician, Dr. X in two to three days for recheck. Return to ED sooner if condition changes or worsen anyway. Discharged in stable condition. ### 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: Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future. He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia. He has been treated by Dr. X through the pediatric neurology clinic. He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems. She also noted and confirmed that he has significant tonsillar hypertrophy. The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech. Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day. He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms. He does have an allergy to penicillin.,I appreciate your input on his care. If you have any questions regarding, please feel free to call me through my office. Otherwise, I look forward to hearing back from you regarding his evaluation. ### Label: Letters ### Response:

Letters

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: DISCHARGE DIAGNOSES:,1. Chronic obstructive pulmonary disease with acute hypercapnic respiratory failure.,2. Chronic atrial fibrillation with prior ablation done on Coumadin treatment.,3. Mitral stenosis.,4. Remote history of lung cancer with prior resection of the left upper lobe.,5. Anxiety and depression.,HISTORY OF PRESENT ILLNESS:, Details are present in the dictated report.,BRIEF HOSPITAL COURSE:, The patient is a 71-year-old lady who came in with increased shortness of breath of one day duration. She denied history of chest pain or fevers or cough with purulent sputum at that time. She was empirically treated with a course of antibiotics of Avelox for ten days. She also received steroids, prednisolone 60 mg, and breathing treatments with albuterol, Ipratropium and her bronchodilator therapy was also optimized with theophylline. She continued to receive Coumadin for her chronic atrial fibrillation. Her heart rate was controlled and was maintained in the 60s-70s. On the third day of admission she developed worsening respiratory failure with fatigue, and hence was required to be intubated and ventilated. She was put on mechanical ventilation from 1/29 to 2/6/06. She was extubated on 2/6 and put on BI-PAP. The pressures were gradually increased from 10 and 5 to 15 of BI-PAP and 5 of E-PAP with FIO2 of 35% at the time of transfer to Kindred. Her bronchospasm also responded to the aggressive bronchodilation and steroid therapy.,DISCHARGE MEDICATIONS:, Prednisolone 60 mg orally once daily, albuterol 2.5 mg nebulized every 4 hours, Atrovent Respules to be nebulized every 6 hours, Pulmicort 500 micrograms nebulized twice every 8 hours, Coumadin 5 mg orally once daily, magnesium oxide 200 mg orally once daily.,TRANSFER INSTRUCTIONS:, The patient is to be strictly kept on bi-level PAP of 15 I-PAP/E-PAP of 5 cm and FIO2 of 35% for most of the times during the day. She may be put on nasal cannula 2 to 3 liters per minute with an O2 saturation of 90-92% at meal times only, and that is to be limited to 1-2 hours every meal. On admission her potassium had risen slightly to 5.5, and hence her ACE inhibitor had to be discontinued. We may restart it again at a later date once her blood pressure control is better if required. ### 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: SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.,CURRENT MEDICATIONS:, The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:, Erythromycin.,REVIEW OF SYSTEMS:, Significant for problems with agitated depression. Her respiratory status is unchanged as noted above.,EXAMINATION:,General: The patient is in no acute distress.,Vital signs: Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular: Distant heart tones. Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1. Chronic obstructive pulmonary disease/emphysema, severe but stable.,2. Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. History of depression and schizophrenia.,PLAN:, At this point, I have recommended that she continue current respiratory medicine. I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. I have recommended that she use it with activity and at night. I spoke with her about her living situation. Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be. ### Label: Cardiovascular / Pulmonary ### 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 OF PRESENT ILLNESS:, Patient is a 50-year-old white male complaining of continued lower back pain. Patient has a history of chronic back pain, dating back to an accident that he states he suffered two years ago. He states he helped a friend unload a motorcycle from a vehicle two-and-a-half days ago, after which he "felt it" in his lower back. The following day (two days ago), he states he rode to Massachusetts and Maine to pick up clients. He feels that this aggravated his chronic back pain as well. He also claims to have a screw in his right hip from a previous surgery to repair a pelvic fracture. He is being prescribed Ultram, Celebrex, gabapentin, and amitriptyline by his PCP for his chronic back pain. He states that his PCP has informed him that he does not prescribe opiate medications for chronic back pain.,The patient did self-refer to another physician, who suggested that he follow up at a pain clinic for his chronic back pain to discuss other alternatives, particularly the medications that the patient feels that he needs. Patient states he did not do this because he was feeling well at that time.,The patient did present to our emergency room last night, at which time he saw Dr. X. He was given a prescription for 12 Vicodin as well as some to take home last night. The patient has not picked up his prescription as of yet and informed the triage nurse that he was concerned that he would not have enough to last through the weekend. Patient states he also has methadone and Darvocet at home from previous prescription and is wondering if he should restart these medicines. He is on several medications, the list of which is attached to the chart.,MEDICATIONS: , In addition to the aforementioned medications, he is on Cymbalta, pantoprazole, and a multivitamin.,ALLERGIES:, HE IS ALLERGIC TO RELAFEN (ITCHING).,SOCIAL HISTORY: , The patient is married and lives with his wife.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse is elevated at 105. Temp and other vitals signs are all within normal limits.,GENERAL: Patient is a middle-aged white male who is sitting on the stretcher in no acute distress.,BACK: Exam of the back shows some generalized tenderness on palpation of the musculature surrounding the lumbar spine, more so on the right than on the left. There is a well-healed upper lumbar incision from his previous L1-L2 fusion. There is no erythema, ecchymosis, or soft-tissue swelling. Mobility is generally very good without obvious signs of discomfort.,HEART: Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS: Clear without rales, rhonchi, or wheezes.,MUSCULOSKELETAL: With the patient supine, there is some discomfort in the lower back with bent-knee flexion of both hips as well as with straight leg abduction of the left leg. There is some mild discomfort on internal and external rotation of the hips as well. DTRs are 1+ at the knees and trace at the ankles.,I explained to the patient that he is suffering from a chronic condition and as his PCP has made it clear that he is unwilling to prescribe opiate medication, which the patient feels that he needs, and he is obligated to follow up at the pain clinic as suggested by the other physician even if he is having a "good day." I explained to him that if he did not investigate other alternatives to what his PCP is willing to prescribe, then on a "bad day," he will have nowhere else to turn. I explained to him that some emergency physicians do chose to use opiates for a short term as Dr. X did last night. It is unclear if the patient is looking for a different opiate medication, but I do not think it is wise to give him more, particularly as he has not even filled the prescription that was given to him last night. I did suggest that he not restart his methadone and Darvocet at this time as he is already on five different medications for his back (Celebrex, tramadol, amitriptyline, gabapentin, and the Vicodin that he was given last night). I did suggest that we could try a different anti-inflammatory if he felt that the Celebrex is not helping. The patient is agreeable to this.,ASSESSMENT,1. Lumbar muscle strain.,2. Chronic back pain.,PLAN: , At this point in time, I felt that it was safe for the patient to transition to heat to his back which he may use as often as possible. Rx for Voltaren 75 mg tabs, dispensed 20, sig. one p.o. q.12h. for pain instead of Celebrex. He may continue with his other medications as directed but not the methadone or Darvocet. I did urge him to reschedule his pain clinic appointment as he was urged to do originally. If unimproved this week, he should follow up with Dr. Y. ### 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: Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:, Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:, The patient denies any past surgical history.,MEDICATIONS:, The patient takes Cardizem CD 240-mg. The patient also takes eye drops.,ALLERGIES:, The patient denies any allergies.,SOCIAL HISTORY:, The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially.,FAMILY HISTORY:, Significant for hypertension and strokes.,REVIEW OF SYSTEMS:, The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:, This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema.,IMPRESSION:, This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.,1. Rule out colon cancer.,2. Rule out colon polyps. ,3. Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:, Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD ### 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: , Severe neurologic or neurogenic scoliosis.,POSTOPERATIVE DIAGNOSIS: , Severe neurologic or neurogenic scoliosis.,PROCEDURES: ,1. Anterior spine fusion from T11-L3.,2. Posterior spine fusion from T3-L5.,3. Posterior spine segmental instrumentation from T3-L5, placement of morcellized autograft and allograft.,ESTIMATED BLOOD LOSS: , 500 mL.,FINDINGS: , The patient was found to have a severe scoliosis. This was found to be moderately corrected. Hardware was found to be in good positions on AP and lateral projections using fluoroscopy.,INDICATIONS: , The patient has a history of severe neurogenic scoliosis. He was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. Risks and benefits were discussed at length with the family over many visits. They wished to proceed.,PROCEDURE:, The patient was brought to the operating room and placed on the operating table in the supine position. General anesthesia was induced without incident. He was given a weight-adjusted dose of antibiotics. Appropriate lines were then placed. He had a neuromonitoring performed as well.,He was then initially placed in the lateral decubitus position with his left side down and right side up. An oblique incision was then made over the flank overlying the 10th rib. Underlying soft tissues were incised down at the skin incision. The rib was then identified and subperiosteal dissection was performed. The rib was then removed and used for autograft placement later.,The underlying pleura was then split longitudinally. This allowed for entry into the pleural space. The lung was then packed superiorly with wet lap. The diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,Once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. This required cauterization of the segmental vessels. Once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. These were performed from T11-L3. This was over 5 levels. Disks and endplates were then removed. Once this was performed, morcellized rib autograft was placed into the spaces. The table had been previously bent to allow for easier access of the spine. This was then straightened to allow for compression and some correction of the curvature.,The diaphragm was then repaired as was the pleura overlying the thoracic cavity. The ribs were held together with #1 Vicryl sutures. Muscle layers were then repaired using a running #2-0 PDS sutures and the skin was closed using running inverted #2-0 PDS suture as well. Skin was closed as needed with running #4-0 Monocryl. This was dressed with Xeroform dry sterile dressings and tape.,The patient was then rotated into a prone position. The spine was prepped and draped in a standard fashion.,Longitudinal incision was made from T2-L5. The underlying soft tissues were incised down at the skin incision. Electrocautery was then used to maintain hemostasis. The spinous processes were then identified and the overlying apophyses were split. This allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. Once this was completed, the C-arm was brought in, which allowed for easy placement of screws in the lumbar spine. These were placed at L4 and L5. The interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. This was done using a rongeur as well as a Kerrison rongeur. Spinous processes were then harvested for morcellized autograft.,Once all the interspaces were prepared, Songer wires were then passed. These were placed from L3-T3.,Once the wires were placed, a unit rod was then positioned. This was secured initially at the screws distally on both the left and right side. The wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where I was operating and then on the right side spine. This allowed for excellent correction of the scoliotic curvature.,Decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. This was done using pulsed lavage.,The wound was then closed in layers. The deep fascia was closed using running #1 PDS suture, subcutaneous tissue was closed using running inverted #2-0 PDS suture, the skin was closed using #4-0 Monocryl as needed. The wound was then dressed with Steri-Strips, Xeroform dry sterile dressings, and tape. The patient was awakened from anesthesia and taken to the intensive care unit in stable condition. All instrument, sponge, and needle counts were correct at the end of the case.,The patient will be managed in the ICU and then on the floor as indicated. ### 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: REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room. I had seen him the day before in my office and recommended him to go into the hospital. He had just come from a trip to Taho in Nevada and he became homicidal while there. He started having thoughts about killing his mother. He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years. He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions. He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too. The patient has not used any drugs since age 25. However, he has continued having intense and frequent psychotic bouts. I have seen him now for approximately one year. He has been quite refractory to treatment. We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary. The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days. The dosages that we have used have been very high. He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level. However, he has not responded.,He has delusions of antichrist. He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals. He has paranoid delusions. He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:, As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:, He stopped using drugs when he was 25. He has got a lapse, but he was more than 10 years and he has been clean ever since then. As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them.,MENTAL STATUS EXAMINATION:, The patient appeared alert, oriented to time, place, and person. His affect is flat. He talked about auditory hallucinations, which are equivocal in nature. He is not homicidal in the hospital as he was when he was at home. His voice and speech are normal. He believes in telepathy. His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I: Schizophrenia.,AXIS II: Deferred.,AXIS III: History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV: Moderate.,AXIS V: GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:, Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment. We will put him on benzodiazepines and make a decision anti-psychotic later. We will make sure that he is safe and that he addresses his medical needs well. ### 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: PROCEDURE: ,The site was cleaned with antiseptic. A local anesthetic (2% lidocaine) was given at each site. A 3 mm punch biopsy was performed in the left calf and left thigh, above the knee. The site was then checked for bleeding. Once hemostasis was achieved, a local antibiotic was placed and the site was bandaged.,The patient was not on any anticoagulant medications. There were also no other medications which would affect the ability to conduct the skin biopsy. The patient was further instructed to keep the site completely dry for the next 24 hours, after which a new Band-Aid and antibiotic ointment should be applied to the area. They were further instructed to avoid getting the site dirty or infected. The patient completed the procedure without any complications and was discharged home.,The biopsy will be sent for analysis.,The patient will follow up with Dr. X within the next two weeks to review her results. ### Label: Dermatology ### Response:

Dermatology

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:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92. ### 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: DISCHARGE DIAGNOSES:,1. Acute respiratory failure, resolved.,2. Severe bronchitis leading to acute respiratory failure, improving.,3. Acute on chronic renal failure, improved.,4. Severe hypertension, improved.,5. Diastolic dysfunction.,X-ray on discharge did not show any congestion and pro-BNP is normal.,SECONDARY DIAGNOSES:,1. Hyperlipidemia.,2. Recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. Remote history of carcinoma of the breast.,4. Remote history of right nephrectomy.,5. Allergic rhinitis.,HOSPITAL COURSE:, This 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. Not long after the patient returned from Mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. X-rays however did not show any congestion or infiltrates and pro-BNP was within normal limits. The patient however was hypoxic and required 4L nasal cannula. She was admitted to the Intensive Care Unit. The patient improved remarkably over the night on IV steroids and empirical IV Lasix. Initial swab was positive for MRSA colonization., ,Discussed with infectious disease, Dr. X and it was decided no treatment was required for de-colonization. The patient's breathing has improved. There is no wheezing or crepitations and O2 saturation is 91% on room air. The patient is yet to go for exercise oximetry. Her main complaint is nasal congestion and she is now on steroid nasal spray. The patient was seen by Cardiology, Dr. Z, who advised continuation of beta blockers for diastolic dysfunction. The patient has been weaned off IV steroids and is currently on oral steroids, which she will be on for seven days.,DISPOSITION: , The patient has been discharged home.,DISCHARGE MEDICATIONS:,1. Metoprolol 25 mg p.o. b.i.d.,2. Simvastatin 20 mg p.o. daily.,NEW MEDICATIONS:,1. Prednisone 20 mg p.o. daily for seven days.,2. Flonase nasal spray daily for 30 days.,Results for oximetry pending to evaluate the patient for need for home oxygen.,FOLLOW UP:, The patient will follow up with Pulmonology, Dr. Y in one week's time and with cardiologist, Dr. X in two to three weeks' time. ### Label: Discharge Summary ### Response:

Discharge Summary

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: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia. She has developed worsening confusion, fever, and intractable diarrhea. She was brought to the emergency department for evaluation. Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6. She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS: ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL: This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT: Examination is normocephalic and atraumatic. The pupils are equal, round and reactive to light and accommodation. The extraocular movements are full.,NECK: Supple with full range of motion and no masses.,LUNGS: There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN: Soft and nontender with no hepatosplenomegaly.,EXTREMITIES: No clubbing, cyanosis or edema.,NEUROLOGIC: The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000. The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1. Elevated white count. This patient is admitted to the hospital for treatment of a febrile illness. There is concern that she has a progression of pneumonia. She may have aspirated. She has been treated with ceftriaxone and clindamycin. I will follow her oxygen saturation and chest x-ray closely. She is allergic to penicillin. Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2. Intractable diarrhea. The patient has been experiencing intractable diarrhea. I am concerned about Clostridium difficile infection with possible pseudomembranous colitis. I will send her stool for Clostridium difficile toxin assay. I will consider treating with metronidazole.,3. Hypokalemia. The patient's profound hypokalemia is likely secondary to her diarrhea. I will treat her with supplemental potassium.,4. DNR status: I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy. , ### 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: SUBJECTIVE:, I am asked to see the patient today with ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. I talked to Anna today. She feels a little fatigued. Otherwise, she is doing well.,PHYSICAL EXAMINATION: ,Vitals as in the chart. The patient is a pleasant and cooperative. She is in no apparent distress.,ASSESSMENT AND PLAN: , Diabetes, still with some problematic low blood glucoses, most notably in the morning. To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning. She will get 55 units in the morning. I am also decreasing once again her Humalog sliding scale insulin prior to meals. I will review the blood glucoses again next week., ### Label: Endocrinology ### Response:

Endocrinology

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:, This is a digital EEG performed on a 75-year-old male with seizures.,BACKGROUND ACTIVITY:, The background activity consists of a 8 Hz to 9 Hz rhythm arising in the posterior head region. This rhythm is also accompanied by some beta activity which occurs infrequently. There are also muscle contractions occurring at 4 Hz to 5 Hz which suggests possible Parkinson's. Part of the EEG is obscured by the muscle contraction artifact. There are also left temporal sharps occurring infrequently during the tracing. At one point of time, there was some slowing occurring in the right frontal head region.,ACTIVATION PROCEDURES:, Photic stimulation was performed and did not show any significant abnormality.,SLEEP PATTERNS:, No sleep architecture was observed during this tracing.,IMPRESSION:, This awake/alert/drowsy EEG is abnormal due to the presence of slowing in the right frontal head region, due to the presence of sharps arising in the left temporal head region, and due to the tremors. The slowing can be consistent with underlying structural abnormalities, so a stroke, subdural hematoma, etc., should be ruled out. The tremor probably represents a Parkinson's tremor and the sharps arising in the left temporal head region can potentially give way to seizures or may also represent underlying structural abnormalities, so clinical correlation is recommended. ### 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: PREOPERATIVE DIAGNOSIS:, Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1. Left elbow manipulation.,2. Hardware removal of left elbow.,ANESTHESIA: ,Surgery was performed under general anesthesia.,COMPLICATIONS:, There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees. We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC: ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.,PROCEDURE: ,The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in a standard surgical fashion. Using fluoroscopy, the patient's K-wire was located. An incision was made over his previous scar. A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles. The K-wires were easily palpable. A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident. The wound was then irrigated. The triceps split was now closed using #2-0 Vicryl. The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl. The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias. A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line. At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION: ,The postoperative films demonstrated no fracture, no retained hardware. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days. The patient is to follow up in 1 week's time for a wound check. The patient was given Tylenol No. 3 for pain. ### 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: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours. ### 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: DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age. ### 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: PREOPERATIVE DIAGNOSES:,1. Nasopharyngeal mass.,2. Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1. Nasopharyngeal tube mass.,2. Right upper lid skin lesion.,PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Excision of nasopharyngeal mass via endoscopic technique.,3. Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan. The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. It appears to be growing in size and is irregularly bordered. After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position. After this, the patient was turned to 90 degrees by the Department of Anesthesia. The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade. After this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors. After this, the ________ was then hemostatically controlled with monopolar cauterization. The patient's skin was then reapproximated with a running #6-0 Prolene suture. A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment. Attention then was drawn to the nasopharynx. The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. The patient had a severely deviated nasal septum more so to the right than the left. There appeared to be a spur on the left inferior aspect and also on the right posterior aspect. The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. After this, the lesion was then removed on the right side with the XPS blade. The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. This area was taken down with the XPS blade. Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter. After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. After this, the patient was then hemostatically controlled with suctioned Bovie cauterization. A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment. The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia. The patient was extubated in the operating room and was transferred to the recovery room in stable condition. The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30. ### 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 DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES: ,1. Right lower extremity radiculopathy with history of post laminectomy pain.,2. Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:, Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root. The left side was quite open; however, that was not the side of her problem. At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root. A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location. After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides. There were no complications. ### Label: Pain Management ### Response:

Pain Management

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: , Hip injection.,INFORMED CONSENT: ,The risks, benefits and alternatives of the procedure were discussed with the patient. The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications. I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing. The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: ,Oxygen saturation and vital signs were monitored continuously throughout the procedure. The patient remained awake throughout the procedure in order to interact and give feedback. The X-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in the prone position on the treatment table. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Fluoroscopy was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine. All injected medications were preservative free. With fluoroscopy, a *** spinal needle was gently guided into the ***. Multiple fluoroscopic views were used to ensure proper needle placement. Approximately *** nonionic contrast agent was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by production of an appropriate arthrogram without concurrent vascular dye pattern. Finally, the treatment solution, consisting of ***. All injected medications were preservative free. Sterile technique was used throughout the procedure,COMPLICATIONS: , None. No complications. The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable. The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day. The patient was told to resume all medications. The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week. ### Label: Pain Management ### Response:

Pain Management

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:, This is a followup dietary consultation for polycystic ovarian syndrome and hyperlipidemia. The patient reports that she has resumed food record keeping which she feels like it has given her greater control. Her physical activity level has remained high. Her struggle times are in the mid-afternoon if she has not had enough food to eat, as well as in the evening after dinner.,OBJECTIVE:, Vital Signs: Weight is 189-1/2 pounds. Food records were reviewed,ASSESSMENT:, The patient has experienced a weight loss of 1-1/2 pounds in the last month. She is commended for these efforts. We have reviewed food records identifying that she has done a nice job keeping a calorie count for the last two or three weeks. We discussed the value of this and how it was very difficulty to resume it, however, after she suspended the record keeping. We also discussed its reflection that she is not getting very many fruits and vegetables on a regular basis. We identified some ways of preventing her from feeling sluggish and having problems with low blood sugar in the middle of the afternoon by routinely planning an afternoon snack that can prevent these symptoms. This will likely be around 2:30 or 3 p.m. for her. We also discussed strategies for evening snacking to help put some definition and boundaries to the snacking.,PLAN:, I recommended the patient routinely include an afternoon snack around 2:30 to 3 p.m. It will be helpful if this snack includes some protein such as nuts or low-fat cheese. She is also encouraged to continue with her record keeping for food choices and calorie points. I also recommended she maintain her high level of physical activity. Will plan to follow the patient in one month for ongoing support. This was a 30-minute consultation. ### 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: DIAGNOSES ON ADMISSION,1. Cerebrovascular accident (CVA) with right arm weakness.,2. Bronchitis.,3. Atherosclerotic cardiovascular disease.,4. Hyperlipidemia.,5. Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1. Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2. Old coronary infarct, anterior aspect of the right external capsule.,3. Acute bronchitis with reactive airway disease.,4. Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5. Atherosclerotic cardiovascular disease.,6. Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room. Plavix was started in addition to baby aspirin. He was kept on oral Zithromax for his cough. He was given Xopenex treatment, because of his respiratory distress. Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid. Dr. X saw him in consultation and recommended CT angiogram. This showed no significant obstructive lesion other than what was known on the ultrasound. Head MRI was done and revealed the above findings. The patient was begun on PT and improved. By discharge, he had much improved strength in his right arm. He had no further progressions. His cough improved with oral Zithromax and nebulizer treatments. His platelets also improved as well. By discharge, his platelets was up to 107,000. His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential. Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate. Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1. PT/INR on admission was 1.03, PTT 34.7. At the time of discharge, the patient's cough was much improved. His right arm weakness has much improved. His lung examination has just occasional rhonchi. He was changed to a metered dose inhaler with albuterol. He is being discharged home. An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation. He will follow up in my office in 1 week. He is to start PT and OT as an outpatient. He is to avoid driving his car. He is to notify, if further symptoms. He has 2 more doses of Zithromax at home, he will complete. His prognosis is good. ### 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: IMPRESSION: ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity. ### 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: HISTORY OF PRESENT ILLNESS: , See chart attached.,MEDICATIONS: , Tramadol 50 mg every 4 to 6 hours p.r.n., hydrocodone 7.5 mg/500 mg every 6 hours p.r.n., zolpidem 10 mg at bedtime, triamterene 37.5 mg, atenolol 50 mg, vitamin D, TriCor 145 mg, simvastatin 20 mg, ibuprofen 600 mg t.i.d., and Lyrica 75 mg.,FAMILY HISTORY: , Mother is age 78 with history of mesothelioma. Father is alive, but unknown medical history as they have been estranged. She has a 51-year-old sister with history of multiple colon polyps. She has 2 brothers, 1 of whom has schizophrenia, but she knows very little about their medical history. To the best of her knowledge, there are no family members with stomach cancer or colon cancer.,SOCIAL HISTORY: , She was born in Houston, Texas and moved to Florida about 3 years ago. She is divorced. She has worked as a travel agent. She has 2 sons ages 24 and 26, both of whom are alive and well. She smokes a half a pack of cigarettes per day for more than 35 years. She does not consume alcohol.,REVIEW OF SYSTEMS: , As per the form filled out in our office today is positive for hypertension, weakness in arms and legs, arthritis, pneumonia, ankle swelling, getting full quickly after eating, loss of appetite, weight loss, which is stated as fluctuating up and down 4 pounds, trouble swallowing, heartburn, indigestion, belching, nausea, diarrhea, constipation, change in bowel habits, change in consistency, rectal bleeding, hemorrhoids, abdominal discomfort and cramping associated with constipation, hepatitis A or infectious hepatitis in the past, and smoking and alcohol as previously stated. Otherwise, review of systems is negative for strokes, paralysis, gout, cataracts, glaucoma, respiratory difficulties, tuberculosis, chest pain, heart disease, kidney stones, hematuria, rheumatic fever, scarlet fever, cancer, diabetes, thyroid disease, seizure disorder, blood transfusions, anemia, jaundice, or pruritus.,PHYSICAL EXAMINATION: ,Weight 152 pounds. Height is 5 feet 3 inches. Blood pressure 136/80. Pulse 68. In general: She is a well-developed and well-nourished female who ambulates with the assistance of a cane. Neurologically nonfocal. Awake, alert, and oriented x 3. HEENT: Head normocephalic, atraumatic. Sclerae anicteric. Conjunctivae are pink. Mouth is moist without any obvious oral lesions. Neck is supple. There is no submandibular, submaxillary, axillary, supraclavicular, or epitrochlear adenopathy appreciable. Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm without obvious gallops or murmurs. Abdomen is soft, nontender with good bowel sounds. No organomegaly or masses are appreciable. Extremities are without clubbing, cyanosis, and/or edema. Skin is warm and dry. Rectal was deferred and will be done at the time of the colonoscopy.,IMPRESSION:,1. A 50-year-old female whose 51-year-old sister has a history of multiple colon polyps, which may slightly increase her risk for colon cancer in the future.,2. Reports of recurrent bright red blood per rectum, mostly on the toilet paper over the past year. Bleeding most likely consistent with internal hemorrhoids; however, she needs further evaluation for colon polyps or colon cancer.,3. Alternations between constipation and diarrhea for the past several years with some lower abdominal cramping and discomfort particularly associated with constipation. She is on multiple medications including narcotics and may have developed narcotic bowel syndrome.,4. A long history of pyrosis, dyspepsia, nausea, and belching for many years relieved by antacids. She may likely have underlying gastroesophageal reflux disease.,5. A 1-year history of some early satiety and fluctuations in her weight up and down 4 pounds. She may also have some GI dysmotility including gastroparesis.,6. Report of dysphagia to solids over the past several years with a history of a bone spur in her cervical spine. If this bone spur is pressing anteriorly, it could certainly cause recurrent symptoms of dysphagia. Differential also includes peptic stricture or Schatzki's ring, and even remotely, the possibility of an esophageal malignancy.,7. A history of infectious hepatitis in the past with some recent mild elevations in AST and ALT levels without clear etiology. She may have some reaction to her multiple medications including her statin drugs, which can cause mild elevations in transaminases. She may have some underlying fatty liver disease and differential could include some form of viral hepatitis such as hepatitis B or even C.,PLAN:,1. We have asked her to follow up with her primary care physician with regard to this recent elevation in her transaminases. She will likely have the lab tests repeated in the future, and if they remain persistently elevated, we will be happy to see her in the future for further evaluation if her primary care physician would like.,2. Discussed reflux precautions and gave literature for further review.,3. Schedule an upper endoscopy with possible esophageal dilatation, as well as colonoscopy with possible infrared coagulation of suspected internal hemorrhoids. Both procedures were explained in detail including risks and complications such as adverse reaction to medication, as well as respiratory embarrassment, infection, bleeding, perforation, and possibility of missing a small polyp or tumor.,4. Alternatives including upper GI series, flexible sigmoidoscopy, barium enema, and CT colonography were discussed; however, the patient agrees to proceed with the plan as outlined above.,5. Due to her sister's history of colon polyps, she will likely be advised to have a repeat colonoscopy in 5 years or perhaps sooner pending the results of her baseline examination., ### 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: CHIEF COMPLAINT:, This 26-year-old male presents today for a complete eye examination.,ALLERGIES:, Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:, Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:, Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:, Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use.,FAMILY HISTORY:, Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:, Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils: Pupil exam reveals round and equally reactive to light and accommodation.,Motility: Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields: Confrontation VF exam reveals full to finger confrontation O.U.,IOP: IOP Method: applanation tonometry OD: 10 mmHg Medications: Alphagan; 0.2% Condition: improving.,Keratometry:,OD: K1 35.875K2 35.875,OS: K1 35.875K2 41.875,Lids/Orbit: Bilateral eyes reveal normal position without infection. Bilateral eyelids reveals white and quiet.,Slit Lamp: Corneal epithelium is intact with normal tear film and without stain. Stroma is clear and avascular. Corneal endothelium is smooth and of normal appearance.,Anterior Segment: Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens: Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment: Posterior segment was dilated bilateral. Bilateral retinas reveal normal color, contour, and cupping.,Retina: Bilateral retinas reveals flat with normal vasculature out to the far periphery. Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected: OD: 20/10 OS: 20/10 OU: 20/15.,REFRACTION:,Lenses - final:,OD: +0.50 +1.50 X 125 Prism 1.75,OS: +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add: OD: +1.00 OS: +1.00,OU: Far VA 20/25,TEST RESULTS:, No tests to report at this time.,IMPRESSION:, Eye and vision exam normal.,PLAN:, Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS: ### 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 PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was then placed in a modified lithotomy position taking great care to pad all extremities. TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis. Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction. A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg. A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 4 other 10/11 mm trocars were placed. Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line. All of the trocars were placed without difficulty. The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula. The gastrohepatic ligament was then identified and incised in an avascular plane. The dissection was carried anteromedially onto the phrenoesophageal membrane. The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice. This incision was extended to the right to allow identification of the right crus. Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus. The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve. This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus. At its left border, the left crus was identified. The dissection plane between it and the left aspect of the esophagus was freed. The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch. By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch. This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel. This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade. The esophagus was lifted by a Babcock inserted through the left upper quadrant port. Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall. Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus. A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus. The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired. Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve. With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left. It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap. The,52-French bougie was used to calibrate the external ring. Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control. The skin incision was approximated with skin staples. A dressing was then applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition. ### Label: Surgery ### 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: EXAM: , Lumbar spine CT without contrast.,HISTORY: , Back pain after a fall.,TECHNIQUE:, Noncontrast axial images were acquired through the lumbar spine. Coronal and sagittal reconstruction views were also obtained.,FINDINGS: , There is no evidence for acute fracture or subluxation. There is no spondylolysis or spondylolisthesis. The central canal and neuroforamen are grossly patent at all levels. There are no abnormal paraspinal masses. There is no wedge/compression deformity. There is intervertebral disk space narrowing to a mild degree at L2-3 and L4-5.,Soft tissue windows demonstrate atherosclerotic calcification of the abdominal aorta, which is not dilated. There was incompletely visualized probable simple left renal cyst, exophytic at the lower pole.,IMPRESSION:,1. No evidence for acute fracture or subluxation.,2. Mild degenerative changes.,3. Probable left simple renal cyst., ### 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: HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety. At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery. Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1. The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration. At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present. The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2. The patient will increase accuracy of yes-no responses to greater than 80% accuracy. She did accomplish this goal. The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established. Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently. The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions. The patient continues to have marked difficulty with her expressive language abilities. She is able to write simple words to help express her basic wants and needs. She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions. A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4. Once again, she made significant improvement and comprehension, but continues to have unintelligible speech. An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device. If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her. Please reconsult at that time if and when the patient is ready to use a speech generating device. The patient is discharged from my services at this time due to a plateau in her progress. Numerous home activities were recommended to allow her to continue to make progress at home. ### Label: Speech - Language ### Response:

Speech - Language

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: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:, Hemangioma, nasal tip.,PROCEDURE PERFORMED: ,1. Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2. Rhinoplasty.,ESTIMATED BLOOD LOSS: ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION: ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma. The hemangioma has involved at her upper tongue. There has not been any change in the last 6 months. We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma. They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries. They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry. They wished to proceed with surgery.,Because of the procedure, informed consent is obtained. The patient is taken to operating room and placed in the supine position. General anesthetic is administrated to an oroendotracheal tube. The face is prepped and draped in the usual manner. The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions. The area is infiltrated with lidocaine with epinephrine. We waited 7 minutes for the hemostatic effect and proceeded with the incision. The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage. This is done in both sides. Further incision is done. A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip. The hemangioma is removed and is found to be involving the medial aspects of both medial crura. This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion. Hemostasis is achieved with electrocautery. Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed. The skin is redraped and the nose found to have satisfactory shape. The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella. Portions of skin and hemangioma are taken laterally on both sides of the columella distally. The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially. The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches. The nose is irrigated and suctioned. The patient tolerated the procedure without complications. I was present and participated in all aspects of the procedure. Sponge and instrument count were complete at the end of the procedure. ### Label: Cosmetic / Plastic Surgery ### Response:

Cosmetic / Plastic 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: ,Severe tonsillitis, palatal cellulitis, and inability to swallow.,HISTORY OF PRESENT ILLNESS: , This patient started having sore throat approximately one week ago; however, yesterday it became much worse. He was unable to swallow. He complained to his parent. He was taken to Med Care and did not get any better, and therefore presented this morning to ER, where seen and evaluated by Dr. X and concerned as whether he had an abscess either pharyngeal, palatal, or peritonsillar. He was noted to have extreme tonsillitis with kissing tonsils, marked exudates especially right side and right palatal cellulitis. A CT scan at ER did not show abscess. He has not had airway compromise, but he has had difficulty swallowing. He may have had a low-grade fever, but nothing marked at home. His records from Hospital are reviewed as well as the pediatric notes by Dr. X. He did have some equivalent leukocytosis. He had a negative monospot and negative strep screen.,PAST MEDICAL HISTORY: ,The patient takes no medications, has had no illnesses or surgeries and he is generally in good health other than being significantly overweight. He is a sophomore at High School.,FAMILY HISTORY: ,Noncontributory to this illness.,SURGERIES: , None.,HABITS: , Nonsmoker, nondrinker. Denies illicit drug use.,REVIEW OF SYSTEMS:,ENT: The patient other than having dysphagia, the patient denies other associated ENT symptomatology.,GU: Denies dysuria.,Orthopedic: Denies joint pain, difficulty walking, etc.,Neuro: Denies headache, blurry vision, etc.,Eyes: Says vision is intact.,Lungs: Denies shortness of breath, cough, etc.,Skin: He states he has a rash, which occurred from penicillin that he was given IM yesterday at Covington Med Care. Mildly itchy. Mother has penicillin allergy.,Endocrine: The patient denies any weight loss, weight gain, skin changes, fatigue, etc, essentially no symptoms of hyper or hypothyroidism.,Physical Exam:,General: This is a morbidly obese white male adolescent, in no acute disease, alert and oriented x 4. Voice is normal. He is handling his secretions. There is no stridor.,Vital Signs: See vital signs in nurses notes.,Ears: TM and EACs are normal. External, normal.,Nose: Opening clear. External nose is normal.,Mouth: Has bilateral marked exudates, tonsillitis, right greater than left. Uvula is midline. Tonsils are touching. There is some redness of the right palatal area, but is not consistent with peritonsillar abscess. Tongue is normal. Dentition intact. No mucosal lesions other than as noted.,Neck: No thyromegaly, masses, or adenopathy except for some small minimally enlarged high jugular nodes.,Chest: Clear to auscultation.,Heart: No murmurs, rubs, or gallops.,Abdomen: Obese. Complete exam deferred.,Skin: Visualized skin dry and intact, except for rash on his inner thighs and upper legs, which is red maculopapular and consistent with possible allergic reaction.,Neuro: Cranial nerves II through XII are intact. Eyes, pupils are equal, round, and reactive to light and accommodation, full range.,IMPRESSION: , Marked exudative tonsillitis, non-strep, non-mono, probably mixed anaerobic infection. No significant prior history of tonsillitis. Possible rash to PENICILLIN.,RECOMMENDATIONS: , I concur with IV clindamycin and IV Solu-Medrol as per Dr. X. I anticipate this patient may need several days of IV antibiotics and then be able to switch over to oral. I do not insist that this patient will need surgical intervention since there is no evidence of abscess. This one episode of severe tonsillitis does not mean the patient needs tonsillectomy, but if he continues to have significant tonsil problems after this he should be referred for ENT evaluation as an outpatient. The patient's parents in the room had expressed good understanding, have a chance to ask questions. At this time, I will see the patient back on an as needed basis. ### 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:, Hawkins IV talus fracture.,POSTOPERATIVE DIAGNOSIS: , Hawkins IV talus fracture.,PROCEDURE PERFORMED:,1. Open reduction internal fixation of the talus.,2. Medial malleolus osteotomy.,3. Repair of deltoid ligament.,ANESTHESIA: , Spinal.,TOURNIQUET TIME: , 90 min.,BLOOD LOSS:, 50 cc.,The patient is in the semilateral position on the beanbag.,INTRAOPERATIVE FINDINGS:, A comminuted Hawkins IV talus fracture with an incomplete rupture of the deltoid ligament. There was no evidence of osteochondral defects of the talar dome.,HISTORY: ,This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle.,It was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed.,PROCEDURE: , The patient was brought back to operative room #4 of ABCD General Hospital on 08/20/03. A spinal anesthetic was administered. A nonsterile tourniquet was placed on the left upper thigh, but not inflated. He was then positioned on the beanbag. The extremity was then prepped and draped in the usual sterile fashion for this procedure. An Esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmHg. At this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site. At this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus. This was curved anteromedial along the root of the saphenous vein. The saphenous vein was located. Its tributaries going plantar were cauterized and the vein was retracted anterolaterally. At this time, we identified the medial malleolus. There was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus. This was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem. It is for this reason that the pedicle, which was attached to the medial malleolus, was left intact. This pedicle was the anterior portion of the deltoid ligament. At this time, a MicroChoice saw was then used to make a box osteotomy of the medial malleolus. Once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply. This provided us with excellent exposure to the fracture site of the medial side. At this time, any loose comminuted pieces were removed. The dome of the talus was also checked and did not reveal any osteochondral defects. There was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site. It is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site. At this time, a reduction was performed. The #7-0 partially threaded cannulated screws were used in order to fix the fracture. At this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,This was placed slightly lateral to the Achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site. Once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in. A depth gauze was then used to measure screw length. A cannulated drill was then used to drill across the fracture site to allow the entrance of the screw. A 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site. Once this was obtained, we checked the reduction again using intraoperative Xi-Scan in the AP and lateral direction. This projection gave us excellent view of our screw placement and excellent compression across the fracture site. At this time, we bone grafted the area of comminution using 1 cc of DynaGraft with crushed cancellous allograft. This was placed using a freer elevator into the fracture site where the comminution was. At this time, we copiously irrigated the wound. The osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps. Two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws. Next, a #1-0 Vicryl was then used to repair the deltoid ligament, which was ruptured via the injury. A tight repair was performed of the deltoid ligament. At this time, again copious irrigation was used to irrigate the wound. A #2-0 Vicryl was then used to approximate the subcutaneous skin and staples for the skin incision. At this time, the leg was cleansed, Adaptic, 4 x 4, and Kerlix roll were then applied. The patient was then placed in a plaster splint for mobilization. The tourniquet was then released. The patient was then transferred off the operating table to recovery in stable condition. The prognosis for this fracture is guarded. There is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk. The patient is aware of this and he will be followed as an outpatient for this problem. ### 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. Adrenal mass, right sided.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSES,1. Adrenal mass, right sided.,2. Umbilical hernia.,OPERATION PERFORMED: , Laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,ANESTHESIA: ,General.,CLINICAL NOTE: , This is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. Procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. Alternative of fully laparoscopic are open surgery or watching the lesion.,DESCRIPTION OF OPERATION: ,In the right flank-up position, table was flexed. He had a Foley catheter in place. Incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed to this.,The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. The vena cava was identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. Specimen was placed in a collection bag, removed intact.,Hemostasis was excellent.,The umbilical hernia had been completely taken down. The edges were freshened up. Vicryl #1 was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar.,Skin closed with clips.,He tolerated the procedure well. All sponge and instrument counts were correct. Estimated blood loss less than 100 mL.,The patient was awakened, extubated, and returned to recovery room in satisfactory condition. ### Label: Surgery ### 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: GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated "lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation. ### 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 OF PRESENT ILLNESS:, Ms. Connor is a 50-year-old female who returns to clinic for a wound check. The patient underwent an APR secondary to refractory ulcerative colitis. Subsequently, she developed a wound infection, which has since healed. On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound. She describes no drainage or erythema from her bottom. She is having good ostomy output. She does not describe any fevers, chills, nausea, or vomiting. The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy. She has been taking Percocet for this pain and it does work. She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain. She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds. This is a pleasant female in no acute distress. The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar. There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant. There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis. Overall, her quality of life has significantly improved since she had her APR. She is functioning well with her ileostomy. She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter. I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less. I have counseled her on refraining from soft drinks and fruit drinks. I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy. She also had questions about her occasional abdominal pain. I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain. I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain. The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery. This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping. I told her that I felt that this would continue to improve as it has done over the past two months since her surgery. I told her to continue doing hand exercises as she has been doing and this seems to be working for her. Overall, I think she has healed from her surgery and is doing very well. Again, her quality of life is significantly improved. She is happy with her performance. We will see her back in six months just for a general routine checkup and see how she is doing at that time. ### 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 DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time. ### 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: , This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker.,OBJECTIVE: , His weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. General exam: The patient is nontoxic and in no acute distress. There is no labored breathing. Psychiatric: He is alert and oriented times 3. Ears: Tympanic membranes pearly gray bilaterally. Mouth: No erythema, ulcers, vesicles, or exudate noted. Eyes: Pupils equal, round, and reactive to light bilaterally. Neck is supple. No lymphadenopathy. Lungs: Clear to auscultation. No rales, rhonchi, or wheezing. Cardiac: Regular rate and rhythm without murmur. Extremities: No edema, cyanosis, or clubbing.,ASSESSMENT: ,1. Palpitations, possibly related to anxiety.,2. Fatigue.,3. Loose stools with some green color and also some nausea. There has been no vomiting, possibly a touch of gastroenteritis going on here.,PLAN: , The patient admits he has been putting this off now for about two weeks. He says his work is definitely contributing to some of his symptoms and he feels stressed. He is leaving for a vacation very soon. Unfortunately, he is actually leaving Wednesday for XYZ, which puts us into a bit of a bind in terms of doing testing on him. My overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. A 12-lead EKG was performed on him in the office today. This EKG was compared with the previous EKG contained in the chart from 2006 and I see that these EKGs look very similar with no significant changes noted, which is definitely a good news. I am going to send him to the lab from our office to get the following tests done: Comprehensive metabolic profile, CBC, urinalysis with reflex to culture and we will also get a chest X-ray. Tomorrow morning I will manage to schedule him for an exercise stress test at Bad Axe Hospital. We were able to squeeze him in. His appointment is at 8:15 in the morning. He is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. I am not going to be here so he is going to see Dr. X. Dr. X should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for XYZ. Certainly, if something comes up we may need to postpone his trip. We petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. In the meantime I have given him Ativan 0.5 mg one tablet two to three times a day as needed for anxiety. I talked about Ativan, how it works. I talked about the side effects. I told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. I took him off of work today and tomorrow so he could rest. ### 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: REVIEW OF SYSTEMS,GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: Negative rash, negative jaundice.,HEMATOPOIETIC: Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.,EYES: Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT: Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY: No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs. **No history of OB/GYN problems.,MUSCULOSKELETAL: Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: See psychiatric evaluation.,ENDOCRINE: No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities. ### 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: PREOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:, Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:, CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM. He was referred for stereotactic radiosurgery. The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits. The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment. He was placed on the treatment table. The Aquaplast mask was constructed. Initial imaging was obtained by the CyberKnife system. The patient was then transported over to the CT scanner at Stanford. Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered. Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices. These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me. I outlined the tumor volume. Inverse treatment planning was used to generate the treatment plan for this patient. This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator. The maximum dose within this center of treatment volume was 23.81 Gy. The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm. The volume treated at the reference dose was 98%. The coverage isodose line was 79%. The conformality index was 1.74 and modified conformality index was 1.55. The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite. He was placed on the treatment table. The Aquaplast mask was applied. Initial imaging was used to bring the patient into optimal position. The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin. He tolerated the procedure well. He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months. The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note. ### 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: HISTORY OF PRESENT ILLNESS: , The patient is a 68-year-old woman whom I have been following, who has had angina. In any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when I spoke to her. I advised her to call 911, which she did. While waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain. By the time she presented here, she is currently pain-free and is feeling well.,PAST CARDIAC HISTORY: , The patient has been having arm pain for several months. She underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia. I had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker. However, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room. On 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80% mid LAD lesion, circumflex normal, and RCA totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area. The decision was made to transfer her as she may be having collateral insufficiency from the LAD stenosis to the RCA vessel. She underwent that with drug-eluting stents on 08/16/08, with I believe three or four total placed, and was discharged on 08/17/08. She had some left arm discomfort on 08/18/08, but this was mild. Yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin. This is her usual angina. She is being admitted with unstable angina post stent.,PAST MEDICAL HISTORY: , Longstanding hypertension, CAD as above, hyperlipidemia, and overactive bladder.,MEDICATIONS:,1. Detrol LA 2 mg once a day.,2. Prilosec for GERD 20 mg once a day.,3. Glucosamine 500/400 mg once a day for arthritis.,4. Multivitamin p.o. daily.,5. Nitroglycerin sublingual as available to her.,6. Toprol-XL 25 mg once a day which I started although she had been bradycardic, but she seems to be tolerating.,7. Aspirin 325 mg once a day.,8. Plavix 75 mg once a day.,9. Diovan 160 mg once a day.,10. Claritin 10 mg once a day for allergic rhinitis.,11. Norvasc 5 mg once a day.,12. Lipitor 5 mg once a day.,13. Evista 60 mg once a day.,ALLERGIES: , ALLERGIES TO MEDICATIONS ARE NONE. SHE DENIES ANY SHRIMP OR SEA FOOD ALLERGY.,FAMILY HISTORY: , Her father died of an MI in his 50s and a brother had his first MI and bypass surgery at 54.,SOCIAL HISTORY: ,She does not smoke cigarettes, abuse alcohol, no use of illicit drugs. She is divorced and lives alone and is a retired laboratory technician from Cornell Diagnostic Laboratory.,REVIEW OF SYSTEMS:, She denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08. No morning headaches or fatigue. No psychiatric diagnosis. No psoriasis, no lupus. Remainder of the review of systems is negative x14 systems except as described above.,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress.,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. She has moist mucosal membranes.,NECK: Veins are not distended. There are no carotid bruits.,LUNGS: Clear to auscultation and percussion without wheezes.,HEART: S1 and S2, regular rate. No significant murmurs, rubs or gallops. PMI nondisplaced.,ABDOMEN: Soft and nondistended. Bowel sounds present.,EXTREMITIES: Without significant clubbing, cyanosis or edema. Pulses grossly intact. Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses.,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. BUN 16 and creatinine 0.9. Glucose 110. Magnesium 2.5. ALT 107 and AST 65 and these were normal on 08/15/08. INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. Aspirin, Plavix, valsartan, Lipitor, and Norvasc. I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence.,Total patient care time in the emergency department 75 minutes. All this was discussed in detail with the patient and her daughter who expressed understanding and agreement. The patient desires full resuscitation status. ### 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: REASON FOR VISIT:, Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:, Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3. Pupils are equal and reactive. EOMs are full. His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400. He has a bitemporal hemianopsia, which is significantly improved and wider. His motor is 5 out of 5. There are no focal motor or sensory deficits. The abdominal incision is well healed. There is no evidence of erythema or collection. The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call. I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him. In addition, he probably will need an MRI prior to any treatment, to follow the residual disease. ### Label: Hematology - Oncology ### Response:

Hematology - Oncology

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: Mr. XYZ forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. For all these reasons, this was not really under the best circumstances and I had to curtail the amount of time I spent trying to get a history because of the physical effort required in extracting information from this patient. The patient was seen late because he had not filled in the patient questionnaire. To summarize the history here, Mr. XYZ who is not very clear on events from the past, sustained a work-related injury some time in 1998. At that time, he was driving an 18-wheeler truck. The patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. He experienced severe low back pain and eventually a short while later, underwent a fusion of L4-L5 and L5-S1. The patient had an uneventful hospital course from the surgery, which was done somewhere in Florida by a surgeon, who he does not remember. He was able to return to his usual occupation, but then again had a second work-related injury in May of 2005. At that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. Mr. XYZ felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. He was MRI'ed at that time, which apparently showed a re-herniation of an L5-S1 disc and then, he somehow ended up in Houston, where he underwent fusion by Dr. W from L3 through S2. This was done on 12/15/2005. Initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. He is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. The patient was referred to Dr. A, pain management specialist and Dr. A has maintained him on opioid medications consisting of Norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with Lunesta 3 mg q.h.s. for sleep, Carisoprodol 350 mg t.i.d., and Lyrica 100 mg q.daily. The patient states that he is experiencing no side effects from medications and takes medications as required. He has apparently been drug screened and his drug screening has been found to be normal. The patient underwent an extensive behavioral evaluation on 05/22/06 by TIR Rehab Center. At that time, it was felt that Mr. XYZ showed a degree of moderate level of depression. There were no indications in the evaluation that Mr. XYZ showed any addictive or noncompliant type behaviors. It was felt at that time that Mr. XYZ would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. Of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. Mr. XYZ indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. He still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. The impression was that the patient had axis IV diagnosis of chronic functional limitations, financial loss, and low losses with no axis III diagnosis. This was done by Rhonda Ackerman, Ph.D., a psychologist. It was also suggested at that time that the patient should quit smoking. Despite these evaluations, Mr. XYZ really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of SSRIs. Of concern in June of 2006 was that the patient had still not stopped smoking despite warnings. His hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. It was felt that any surgical interventions should be put on hold at that time. In September of 2006, the patient was evaluated at Baylor College of Medicine in the Occupational Health Program. The evaluation was done by a physician at that time, whose report is clearly documented in the record. Evaluation was done by Dr. B. At present, Mr. XYZ continues on with his oxycodone and Norco. These were prescribed by Dr. A two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. The patient states that there has been no recent change in either the severity or the distribution of his pain. He is unable to sleep because of pain and his activities of daily living are severely limited. He spends most of his day lying on the floor, watching TV and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. The patient denies smoking at this time. He denies alcohol use or aberrant drug use. He obtains no pain medications from no other sources. Review of MRI done on 02/10/06 shows laminectomies at L3 through S1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left L4-5 and S1 nerve roots, which appear to be retracted posteriorly. There is a small right posterior herniation at L1-L2.,PAST MEDICAL HISTORY:, Significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. The patient does not know what medications he is taking for diabetes and denies any diabetes. CABG in July of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. History of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,SOCIAL HISTORY:, The patient is on disability. He does not smoke. He does not drink alcohol. He is single. He lives with a girlfriend. He has minimal activities of daily living. The patient cannot recollect when last a urine drug screen was done.,REVIEW OF SYSTEMS:, No fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. Depressive symptoms of crying and decreased self-worth have been noted in the past. No neurological history of strokes, epileptic seizures. Genitourinary negative. Gastrointestinal negative. Integumentary negative. Behavioral, depression.,PHYSICAL EXAMINATION:, The patient is short of hearing. His cognitive skills appear to be significantly impaired. The patient is oriented x3 to time and place. Weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. The patient is complaining of pain of a 9/10.,Musculoskeletal: The patient's gait is markedly antalgic with predominant weightbearing on the left leg. There is marked postural deviation to the left. Because of pain, the patient is unable to heel-toe or tandem gait. Examination of the neck and cervical spine are within normal limits. Range of motion of the elbow, shoulders are within normal limits. No muscle spasm or abnormal muscle movements noted in the neck and upper extremities. Head is normocephalic. Examination of the anterior neck is within normal limits. There is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. Skin is normal. Hair distribution normal. Skin temperature normal in both the upper and lower extremities. The lumbar spine curvature is markedly flattened. There is a well-healed central scar extending from T12 to L1. The patient exhibits numerous positive Waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. Examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. Range of motion testing of the lumbar spine is labored in all directions. It is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. There is a marked degree of sciatic notch tenderness on the left. No abnormal muscle spasms or muscle movements were noted. Patrick's test is negative bilaterally. There are no provocative facetal signs in either the left or right quadrants of the lumbar area. Neurological exam: Cranial nerves II through XII are within normal limits. Neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. Neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. There is no ankle clonus. Babinski is negative. Sensory testing shows a minimal degree of sensory loss on the right L5 distribution. Muscle testing shows decreased L4-L5 on the left with extensor hallucis longus +2/5. Ankle extensors are -3 on the left and +5 on the right. Dorsiflexors of the left ankle are +2 on the left and +5 on the right. Straight leg raising test is positive on the left at about 35 . There is no ankle clonus. Hoffman's test and Tinel's test are normal in the upper extremities.,Respiratory: Breath sounds normal. Trachea is midline.,Cardiovascular: Heart sounds normal. No gallops or murmurs heard. Carotid pulses present. No carotid bruits. Peripheral pulses are palpable.,Abdomen: Hernia site is intact. No hepatosplenomegaly. No masses. No areas of tenderness or guarding.,IMPRESSION:,1. Post-laminectomy low back syndrome.,2. Left L5-S1 radiculopathy.,3. Severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. Opioid dependence for pain control.,TREATMENT PLAN:, The patient will continue on with his medications prescribed by Dr. Chang and I will see him in two weeks' time and probably suggest switching over from OxyContin to methadone. I do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. I will get a behavioral evaluation from Mr. Tom Welbeck and refer the patient for ongoing physical therapy. The prognosis here for any improvement or return to work is zero. ### Label: Orthopedic ### 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: CHIEF COMPLAINT:, Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS: The patient was afebrile. He is slightly tachycardic, 105, but stable blood pressure and respiratory rate. GENERAL: The patient is in no distress. Sitting quietly on the gurney. HEENT: Unremarkable. His oral mucosa is moist and well hydrated. Lips and tongue look normal. Posterior pharynx is clear. NECK: Supple. His trachea is midline. There is no stridor. LUNGS: Very clear with good breath sounds in all fields. There is no wheezing. Good air movement in all lung fields. CARDIAC: Without murmur. Slight tachycardia. ABDOMEN: Soft, nontender. SKIN: Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. He noted some on his buttocks as well. Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:, ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. In the meantime, I think he can be managed with some antihistamine over-the-counter. He is responding already to Benadryl and the epinephrine that we gave him here. He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. He is discharged in stable condition. ### 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: We discovered new T-wave abnormalities on her EKG. There was of course a four-vessel bypass surgery in 2001. We did a coronary angiogram. This demonstrated patent vein grafts and patent internal mammary vessel and so there was no obvious new disease.,She may continue in the future to have angina and she will have nitroglycerin available for that if needed.,Her blood pressure has been elevated and so instead of metoprolol, we have started her on Coreg 6.25 mg b.i.d. This should be increased up to 25 mg b.i.d. as preferred antihypertensive in this lady's case. She also is on an ACE inhibitor.,So her discharge meds are as follows:,1. Coreg 6.25 mg b.i.d.,2. Simvastatin 40 mg nightly.,3. Lisinopril 5 mg b.i.d.,4. Protonix 40 mg a.m.,5. Aspirin 160 mg a day.,6. Lasix 20 mg b.i.d.,7. Spiriva puff daily.,8. Albuterol p.r.n. q.i.d.,9. Advair 500/50 puff b.i.d.,10. Xopenex q.i.d. and p.r.n.,I will see her in a month to six weeks. She is to follow up with Dr. X before that. ### 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: REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:, The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite well as well. He has had no symptoms of hyperglycemia or hypoglycemia. He has had no falls. His right knee does pain him at times and he is using occasional doses of Tylenol for that. He wonders whether he could use a knee brace to help him with that issue as well. His spirits are good. He has had no incontinence. His memory is clear, as is his thinking.,MEDICATIONS:,1. Bumex - 2 mg daily.,2. Aspirin - 81 mg daily.,3. Lisinopril - 40 mg daily.,4. NPH insulin - 65 units in the morning and 25 units in the evening.,5. Zocor - 80 mg daily.,6. Toprol-XL - 200 mg daily.,7. Protonix - 40 mg daily.,8. Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:, Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%. He is afebrile. JVP is normal without HJR. CTAP. RRR. S1 and S2. Aortic murmur unchanged. Abdomen: Soft, NT without HSM, normal BS. Extremities: No edema on today's examination. Awake, alert, attentive, able to get up on to the examination table under his own power. Able to get up out of a chair with normal get up and go. Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3. A1c 7.6 down from 8.5. Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1. Congestive heart failure, stable on current regimen. Continue.,2. Diabetes type II, A1c improved with increased doses of NPH insulin. Doing self-blood glucose monitoring with values in the morning between 100 and 130. Continue current regimen. Recheck A1c on return.,3. Hyperlipidemia, at last visit, he had 3+ protein in his urine. TSH was normal. We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia. In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia. Specifically we were considering TriCor (fenofibrate). Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy. We will leave open for the future. Check fasting lipid panel today.,4. Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5. Arthritis, stable. I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day. He states he will inch that up slowly. With regard to a brace, he stated he used one in the past and that did not help very much. I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease. For now he will continue with his cane and walker.,6. Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed. ### 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: CHIEF COMPLAINT:, Cut on foot.,HISTORY OF PRESENT ILLNESS:, This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.,PAST MEDICAL HISTORY:, Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16. Oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well-nourished, well-developed, the patient appears to be healthy. The patient is calm and comfortable in no acute distress and looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear conjunctiva and cornea bilaterally. NECK: Supple with full range of motion. CARDIOVASCULAR: Peripheral pulse is +2 to the right foot. Capillary refills less than two seconds to all the digits of the right foot. RESPIRATIONS: No shortness of breath. MUSCULOSKELETAL: The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot. There is no palpable foreign body, no foreign body is visualized. There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels. It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home. The patient does not have any tenderness to the foot. The patient has full range of motion to all the joints, all the toes, as well as the ankles. The patient ambulates well without any difficulty or discomfort. There are no other injuries noted to the rest of the body. SKIN: The 4-mm partial thickness laceration to the right foot as previously described. No other injuries are noted. NEUROLOGIC: Motor is 5/5 to all the muscle groups of the right lower extremity. Sensory is intact to light touch to all the dermatomes of the right foot. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No active bleeding is occurring at this time. No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:, The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1. A 4-MM LACERATION TO THE RIGHT FOOT.,2. ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, To home. The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection. The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on. ### Label: General Medicine ### 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: CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops. ### 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: REASON FOR VISIT:, Lap band adjustment.,HISTORY OF PRESENT ILLNESS:, Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. She was alert and oriented in no apparent distress. ,PROCEDURE: ,I was able to access her port. She does have an AP standard low profile. I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. She will come back in two weeks for another adjustment as needed., ### Label: Surgery ### 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 comes back to see me today. She is a pleasant 77-year-old Caucasian female who had seen Dr. XYZ with right leg pain. She has a history of prior laminectomy for spinal stenosis. She has seen Dr. XYZ with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right L2 radiculopathy, which is symptomatic. Dr. XYZ had performed two right L2-L3 transforaminal epidural injections, last one in March 2005. She was subsequently seen and Dr. XYZ found most of her remaining symptoms are probably coming from her right hip. An x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study. Dr. XYZ had performed right intraarticular hip injection on 04/07/2005. She was last seen on 04/15/2005. At that time, she had the hip injection that helped her briefly with her pain. She is not sure whether or not she wants to proceed with hip replacement. We recommend she start using a cane and had continued her on some pain medicines.,The patient comes back to see me today. She continues to complain of significant pain in her right hip, especially with weightbearing or with movement. She said she had made an appointment to see an orthopedic surgeon in Newton as it is closer and more convenient for her. She is taking Ultracet or other the generic it sounds like, up to four times daily. She states she can take this much more frequently as she still has significant pain symptoms. She is using a cane to help her ambulate.,PAST MEDICAL HISTORY:, Essentially unchanged from her visit of 04/15/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 4 inches. Weight is 149 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.,Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.,Spine: Examination shows lumbar scoliosis with surgical scar with no major tenderness. Spinal movements are limited but functional.,Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensations are intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Degenerative disk disease of the right hip, symptomatic.,2. Low back syndrome, lumbar spinal stenosis, clinically right L2 radiculopathy, stable.,3. Low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4. Facet and sacroiliac joint syndrome on the right, stable.,5. Post left hip arthroplasty.,6. Chronic pain syndrome.,RECOMMENDATIONS:, The patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement. In the interim, her Ultracet is not quite taking care of her pain. I have asked her to discontinue it and we will start her on Tylenol #3, up to four times a day. I have written a prescription for this for 120 tablets and two refills. The patient will call for the refills when she needs them. I will plan further follow up in six months, sooner if needed. She voiced understanding and is in agreement with this plan. Physical exam findings, history of present illness and recommendations were performed with and in agreement with Dr. Goel's findings. ### 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: PREOPERATIVE DIAGNOSIS:, Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe. The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe. The patient presents n.p.o. since mid night last night and consented to sign in the chart. H&P is complete.,PROCEDURE IN DETAIL:, After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position. Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time. Restraining, a lap belt was then placed around the patient's abdomen while laying on the table. After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia. The foot was then prepped and draped in the normal sterile orthopedic manner. The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg. The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed. A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup. Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue. Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin. This was performed with the combination of blunt and dull dissection. Care was taken to avoid proper digital arteries and neurovascular bundles as were identified. Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint. The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure. Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup. It was elevated with fresh #15 blade. The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally. Following this, the distal portion of the tendon was identified in a like manner. The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone. The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues. Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected. Care was taken to avoid the deep flexor tendon. The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology. The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment. The digit was also noted to be in rectus alignment. Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity. Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue. Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin. The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site. Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin. The toe was bandaged using 4 x 4s, Kling, and Coban. The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe. Total tourniquet time for the case was 30 minutes. While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot. The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain. The patient was also given prescription for cane to aid in ambulation. The patient will followup with Dr. X on Tuesday in his office for postoperative care. The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit. The patient tolerated the procedure well and the anesthesia with no 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: PREOPERATIVE DIAGNOSIS:, Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:, Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:, The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted. Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses. The profundus and the cardia of the stomach were unremarkable. The pylorus was concentric. The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position. She was given IV sedation using Demerol and Versed. Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus. Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep. The above gross findings noted. The panendoscope was withdrawn back from the stomach, deflected upon itself. The lesser curve fundus and cardiac were well visualized. Upon examination of these areas, panendoscope was returned to midline. Photographs and biopsies were obtained of the antrum of the stomach. Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate. The patient is sent to recovery room in stable 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: REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week. She has had no problems with methotrexate as far as she knows. She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth. About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic. Although she claims she remembers taking this type of medication in the past without any problems. She was on that medication three pills a day for three to four days. She notes no other problems with her skin. She remembers no allergic reactions to medication. She has no previous history of fever blisters. ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips. The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva. Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today. There did however appear to be one small erosion on the soft palate. Examination of the rest of her skin revealed no areas of dermatitis or blistering. There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries. ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. ,I am not as familiar with the NSAID causing an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis. ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid. I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue. Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions. It can be applied t.i.d. ,Thank you very much for allowing me to share in the care of this pleasant patient. I will follow her with you as 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: NAME OF PROCEDURES,1. Selective coronary angiography.,2. Left heart catheterization.,3. Left ventriculography.,PROCEDURE IN DETAIL: ,The right groin was sterilely prepped and draped in the usual fashion. The area of the right coronary artery was anesthetized with 2% lidocaine and a 4-French sheath was placed. Conscious sedation was obtained using a combination of Versed 1 mg and fentanyl 50 mcg. A left #4, 4-French, Judkins catheter was placed and advanced through the ostium of the left main coronary artery. Because of difficulty positioning the catheter, the catheter was removed and a 6-French sheath was placed and a 6-French #4 left Judkins catheter was placed. This was advanced through the ostium of the left main coronary artery where selective angiograms were performed. Following this, the 4-French right Judkins catheter was placed and angiograms of the right coronary were performed. A pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram. The left heart pullback was performed. The catheter was removed and a small injection of contrast was given to the sheath. The sheath was removed over a wire and an Angio-Seal was placed. There were no complications. Total contrast media was 200 mL of Optiray 350. Fluoroscopy time 5.3 minutes. Total x-ray dose is 1783 mGy.,HEMODYNAMICS: ,Rhythm is sinus throughout the procedure. LV pressure of 155/22 mmHg, aortic pressure of 160/80 mmHg. LV pullback demonstrates no gradient.,The right coronary artery is a nondominant vessel and free of disease. This also gives rise to the conus branch and two RV free wall branches. The left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%. This vessel then bifurcates into the LAD and circumflex. The circumflex is a large caliber vessel and is dominant. This vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the PDA. There was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity. The origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity. The distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and PDA.,The proximal LAD is ectatic. The LAD gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal. Distal to the origin of this diagonal branch, there is another area of ectasia in the LAD, followed by an area of stenosis that in some views is approximately 50% in severity.,The left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall. The overall ejection fraction is preserved. There is moderate dilatation of the aortic root. The calculated ejection fraction is 63%.,IMPRESSION,1. Left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2. Coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery. There is subtotal stenosis at the origin of the first obtuse marginal artery.,3. A 60% stenosis in the distal circumflex.,4. Ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5. Severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch. ### 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: REASON FOR VISIT:, Kidney transplant.,HISTORY OF PRESENT ILLNESS: , The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006. He had to back down on his WelChol because of increased backache. He actually increased his Pravachol and is tolerating this with minimal problems. He comes in for followup.,ALLERGIES: , Aspirin and Altace caused cough, Lipitor and Pravachol at higher doses caused myalgias, Zetia caused myalgias.,MEDICATIONS:, Gengraf 125/50 mg daily, CellCept 500 mg q.i.d., acyclovir 800 mg q.i.d., DexFol daily, ferrous sulfate Mondays, Wednesdays and Fridays, metoprolol 50 mg b.i.d., vitamin C daily, baby aspirin 81 mg daily, Bactrim Single Strength daily, Cozaar 50 mg daily, WelChol 625 mg daily, and Pravachol 10 mg daily.,PAST MEDICAL HISTORY:,1. ESRD secondary to hypertension.,2. Cadaveric kidney in February 2006.,3. Gunshot wound in Southeast Asia.,4. Hyperlipidemia.,REVIEW OF SYSTEMS: , Cardiovascular: No chest pain, dyspnea on exertion, orthopnea, PND or edema. GU: No hematuria, foamy urine, pyuria, frequency or dysuria. He has occasional tingling over his graft, but this is not bothering him today.,PHYSICAL EXAMINATION:, VITAL SIGNS: Pulse 82. Blood pressure is 108/64. Weight is 64.5 kg. GENERAL: He is in no apparent distress. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear bilaterally. ABDOMEN: Soft, nontender, and nondistended. Multiple scars. Right lower quadrant graft is unremarkable. EXTREMITIES: No edema.,LABORATORY DATA:, Labs dated 07-11-06, hematocrit 34.8, sodium 137, magnesium 1.9, potassium 4.9, chloride 102, CO2 25, BUN is 37, creatinine is 1.3, calcium 10.1, phosphorus 3.7, and albumin 4.4. LFTs unremarkable. Cholesterol 221, triglycerides 104, HDL 42, LDL 158, and cyclosporine 163.,IMPRESSION:,1. Status post cadaveric kidney transplant with stable function.,2. Hypertension under excellent control.,3. Hyperlipidemia not at goal. He simply is not tolerating higher doses of medications.,PLAN:,1. We will add over-the-counter fish oil b.i.d.,2. Continue all current medications.,3. Recheck labs today including urinalysis.,4. He will see transplant in two weeks and me in four weeks. We will plan to send urine for decoy cells on his next visit. ### Label: Nephrology ### Response:

Nephrology

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. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2. Diabetes.,3. Peripheral vascular disease.,POSTOPERATIVE DIAGNOSES,1. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.,2. Diabetes.,3. Peripheral vascular disease.,OPERATIONS,1. Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue.,2. Secondary closure of wound, complicated.,3. VAC insertion.,DESCRIPTION OF PROCEDURE:, After obtaining an informed consent, the patient was brought to the operating room where a general anesthetic was given. A time-out process was followed. All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion.,The xenograft was not adhered at all and was easily removed. There was some, what appeared to be a seropurulent exudate at the bottom of the incision. This was towards the abdominal end, under the xenograft.,The graft was fully exposed and it was pulsatile. We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft. A few areas of necrotic skin and subcutaneous tissue were debrided. Prior to this, samples were taken for aerobic and anaerobic cultures.,Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it. There was a separate incision, which was bridged __________ to the incision of the abdomen, which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound. Prior to that, I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge. Multiple layers were applied to seal the system, which was suctioned and appeared to be working satisfactorily.,The patient tolerated the procedure well and was sent to the ICU for recovery. ### 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. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,POSTOPERATIVE DIAGNOSES:,1. Oxygen dependency.,2. Chronic obstructive pulmonary disease.,PROCEDURES PERFORMED:,1. Tracheostomy with skin flaps.,2. SCOOP procedure FastTract.,ANESTHESIA: , Total IV anesthesia.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: ,None.,INDICATIONS FOR PROCEDURE: , The patient is a 55-year-old Caucasian male with a history of chronic obstructive pulmonary disease and O2 dependency of approximately 5 liters nasal cannula at home. The patient with extensive smoking history who presents after risks, complications, and consequences of the SCOOP FastTract procedure were explained.,PROCEDURE:, The patient was brought to operating suite by Anesthesia and placed on the operating table in the supine position. After this, the patient was then placed under total IV anesthesia and the operating bed was then placed in reverse Trendelenburg. The patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. The midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. After this, the patient was then prepped and draped with Hibiclens. A skin incision was then made in the midline with a #15 Bard-Parker in a vertical fashion. After this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed Vicryl ties. Further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. The patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. Cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. The anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. The cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. Stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. After this, the patient's anterior trachea was then identified and cleaned with pusher. After this, the cricoid cartilage along the first and second tracheal rings was identified. The cricoid hook was placed and the trachea was brought more anteriorly and superiorly. After this, the patient's head incision was placed below the second tracheal ring with a #15 Bard-Parker. After this, the patient had a tracheal punch with the SCOOP FastTract kit to create a small 4 mm punch within the tracheal cartilage. After this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a Vicryl strap. After this, the cricoid hook was removed and the patient then had FiO2 on the monitor noted with pulse oximetry of 100%. The patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. The patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. The patient will have the stent guidewire removed with a scoop catheter 11 cm placed. ### 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 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus. An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt. There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821. An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy. The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE: ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries. The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle. A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt. Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm. The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta. This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta. Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery. Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter. Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus. The left-sided heart was fully saturated. The phasic right-sided and left-sided pressures were normal. The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1. Vascular resistances were normal. A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt. The branch pulmonary arteries appeared normal. There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation. No evidence of residual left-to-right shunt. There is no change in right-sided pressures. There is a slight increase in the left-sided phasic pressures. Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1. Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery. There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS): ,Coil embolization of patent ductus arteriosus.,MANAGEMENT: ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram. Further patient care be directed by Dr. X., ### Label: Cardiovascular / Pulmonary ### 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: OCULAR FINDINGS: , Anterior chamber space: Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole. No dilated blood vessels seen in each eye.,Periphery: The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION: ,Premature retina and vitreous, each eye.,PLAN: ,Recheck in two weeks., ### 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: EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,This is a 53-year-old female with left knee pain being evaluated for ACL tear.,FINDINGS:,This examination was performed on 10-14-05.,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is a discoid lateral meniscus and although there may be minimal superficial fraying along the inner edge of the body, there is no discrete tear (series #6 images #7-12).,There is a near-complete or complete tear of the femoral attachment of the anterior cruciate ligament. The ligament has a balled-up appearance consistent with at least partial retraction of most of the fibers of the ligament. There may be a few fibers still intact (series #4 images #12-14; series #5 images #12-14). The tibial fibers are normal.,Normal posterior cruciate ligament.,There is a sprain of the medial collateral ligament, with mild separation of the deep and superficial fibers at the femoral attachment (series #7 images #6-12). There is no complete tear or discontinuity and there is no meniscocapsular separation.,There is a sprain of the lateral ligament complex without focal tear or discontinuity of any of the intraarticular components.,Normal iliotibial band.,Normal quadriceps and patellar tendons.,There is contusion within the posterolateral corner of the tibia. There is also contusion within the patella at the midline patellar ridge where there is an area of focal chondral flattening (series #8 images #10-13). The medial and lateral patellar facets are otherwise normal as is the femoral trochlea in the there is no patellar subluxation.,There is a mild strain of the vastus medialis oblique muscle extending into the medial patellofemoral ligament and medial patellar retinaculum but there is no complete tear or discontinuity.,Normal lateral patellar retinaculum. There is a joint effusion and plica.,IMPRESSION:, Discoid lateral meniscus without a tear although there may be minimal superficial fraying along the inner edge of the body. Near-complete if not complete tear of the femoral attachment of the anterior cruciate ligament. Medial capsule sprain with associated strain of the vastus medialis oblique muscle. There is focal contusion within the patella at the midline patella ridge. Joint effusion and plica. ### 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:, Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:, Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE: ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina. For this reason, Dr. X and I agreed to operate on this patient together. Please note that two surgeons were required for this case due to the complexity of it. The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position. General endotracheal anesthesia was given with a double lumen tube. The patient was positioned for a left thoracotomy. All pressure points were carefully padded. The patient was prepped and draped in usual sterile fashion. A muscle sparing incision was created several centimeters anterior to the tip of the scapula. The serratus and latissimus muscles were retracted. The intercostal space was opened. We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization. Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass. This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta. The lung was deflated and allowed to retract anteriorly. With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass. We began by opening the tumor and taking a very wide large biopsy. This was sent for frozen section, which revealed a benign nerve sheath tumor. Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass. This left the external surface of the mass much more malleable and easier to retract. Using a bipolar cautery and endoscopic scissors we were then able to completely resect it. Once the tumor was resected, it was then sent for permanent sections. The entire hemithorax was copiously irrigated and hemostasis was complete. In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space. A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace. The wounds were then closed in multiple layers. A #2 Vicryl was used to approximate the ribs. The muscles of the chest wall were allowed to return to their normal anatomic position. A 19 Blake was placed in the subcutaneous tissues. Subcutaneous tissues and skin were closed with running absorbable sutures. The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable 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: PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:, GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the recovery room in a satisfactory condition.,INDICATION FOR PROCEDURE: ,The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. The patient was taken to the operating room for an I&D of the lacerations with wound closure.,PROCEDURE IN DETAIL: ,After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5. Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed. It was noted that the head was significantly contaminated with blood as well as mangled. It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair. This was shaved appropriately with shavers. Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide. Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline. No significant debris was appreciated. Once this was done, staples were used to oppose the dermal edges together. The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape. The neck procedure was subsequently performed. ### 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 INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman. He is complaining chiefly of persistent lower back pain. He states the pain is of a rather constant nature. He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back. He states he has difficulty with prolonged standing or sitting. He can only stand for about 5-10 minutes, then he has to sit down. He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain. He has difficulty with bending and stooping maneuvers. He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot. He gets numbness along the lateral aspect of the foot itself. He also describes chronic pain complaints with associated tension in the back of his neck. He states the pain is of a constant nature in his neck. He states he gets pain that radiates into the right shoulder girdle area and the right forearm. He describes some numbness along the lateral aspect of the right forearm. He states he has trouble trying to use his arm at or above shoulder height. He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity. He describes pain at the anterior aspect of his shoulder, in particular. He denies any headache complaints. He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person. He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck. He lost his footing and fell. He reached out to grab the hand railing. He fell backwards on his back and his right shoulder. He had immediate onset of shoulder pain, neck pain, and low back pain. He had pain into his right leg. He initially came under the care of Dr. H, an occupational physician in Modesto. Initially, he did not obtain any MRIs or x-rays. He did undergo some physical therapy and received some medications. Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful. The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990. He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat. He continues with rather persistent pain in his right shoulder. He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff. The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories. He felt that the patient might require a cortisone injection or possibly a surgical intervention. The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck. There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels. The patient was also seen by Dr. P, a neurologist for a Neurology consult. It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities. The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994. He returned back to regular duty. Dr. N declared him permanent and stationary on 04/04/1995. The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer. At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician. Dr. N took him off work again. He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon. He had a new MRI of his lumbar spine performed. The MRI was performed on 05/20/1997. It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis. The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam. Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation. Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive. The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left. Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities. The patient did see Dr. R for a neurosurgical consult. Dr. R evaluated both his neck and lower back pain complaints on several occasions. Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks. The patient underwent these injections with Dr. K. The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections. It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine. Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness. The patient also was noted to have a C4-5 with rather severe degenerative disc disease. He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6. Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease. He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1. He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain. He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms. He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him. He is currently taking no medications to manage his pain complaints. He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury. He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician. The patient states he has not been back to work since. He has since applied for social security disability and now is receiving social security disability benefits. The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful. Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay., ### Label: IME-QME-Work Comp etc. ### 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: OPERATION,1. Ivor-Lewis esophagogastrectomy.,2. Feeding jejunostomy.,3. Placement of two right-sided #28-French chest tubes.,4. Right thoracotomy.,ANESTHESIA: ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered. Prior to administration of general anesthesia, the patient had an epidural anesthesia placed. In addition, he had a dual-lumen endotracheal tube placed. The patient was placed in the supine position to begin the procedure. His abdomen and chest were prepped and draped in the standard surgical fashion. After applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus. Dissection was carried down through the linea using Bovie electrocautery. The abdomen was opened. Next, a Balfour retractor was positioned as well as a mechanical retractor. Next, our attention was turned to freeing up the stomach. In an attempt to do so, we identified the right gastroepiploic artery and arcade. We incised the omentum and retracted it off the stomach and gastroepiploic arcade. The omentum was divided using suture ligature with 2-0 silk. We did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk. Next, we turned our attention to performing a Kocher maneuver. This was done and the stomach was freed up. We took down the falciform ligament as well as the caudate attachment to the diaphragm. We enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest. We also did a portion of the esophageal dissection from the abdomen into the chest area. The esophagus and the esophageal hiatus were identified in the abdomen. We next turned our attention to the left gastric artery. The left gastric artery was identified at the base of the stomach. We first took the left gastric vein by ligating and dividing it using 0 silk ties. The left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement. At this point the stomach was freely mobile. We then turned our attention to performing our jejunostomy feeding tube. A 2-0 Vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of Treitz. We then used Bovie electrocautery to open the jejunum at this site. We placed a 16-French red rubber catheter through this site. We tied down in place. We then used 3-0 silk sutures to perform a Witzel. Next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties. After doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen. This was done with #1 Prolene. We put in a 2nd layer of 2-0 Vicryl. The skin was closed with 4-0 Monocryl.,Next, we turned our attention to performing the thoracic portion of the procedure. The patient was placed in the left lateral decubitus position. The right chest was prepped and draped appropriately. We then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion. Dissection was carried down to the level of the ribs with Bovie electrocautery. Next, the ribs were counted and the 5th interspace was entered. The lung was deflated. We placed standard chest retractors. Next, we incised the peritoneum over the esophagus. We dissected the esophagus to just above the azygos vein. The azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties. As mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus. After doing this, we backed our NG tube out to above the level where we planned to perform our pursestring. We used an automatic pursestring and applied. We then transected the proximal portion of the stomach with Metzenbaum scissors. We secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus. The pursestring was then tied down without difficulty. Next, we tabularized our stomach using a #80 GIA stapler. After doing so, we chose a portion of the stomach more distally and opened it using Bovie electrocautery. We placed our EEA stapler through it and then punched out through the gastric wall. We connected our anvil to the EEA stapler. This was then secured appropriately. We checked to make sure that there was appropriate muscle apposition. We then fired the stapler. We obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology. We also sent the gastroesophageal specimen for pathology. Of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins. We then turned our attention to closing the gastrostomy opening. This was closed with 2-0 Vicryl in a running fashion. We then buttressed this with serosal 3-0 Vicryl interrupted sutures. We returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it. Next, we placed two #28-French chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis. We then closed the chest with #2 Vicryl in an interrupted figure-of-eight fashion. The lung was brought up. We closed the muscle layers with #0 Vicryl followed by #0 Vicryl; then we closed the subcutaneous layer with 2-0 Vicryl and the skin with 4-0 Monocryl. Sterile dressing was applied. The instrument and sponge count was correct at the end of the case. The patient tolerated the procedure well and was extubated in the operating room and transferred to the ICU in good condition. ### 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: CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73. HR 71. RR 21. Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits. ### 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: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted. This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:, Conscious sedation was achieved via propofol via the emergency department staff. Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture. This was confirmed with image intensifier. Subsequently, the patient was placed into a splint. The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION: ,Post-reduction x-rays revealed good alignment in the AP x-rays. The lateral x-rays also revealed adequate reduction. At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week. ### 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:, One-month followup.,HISTORY OF PRESENT ILLNESS:, The patient is an 88-year-old Caucasian female. She comes here today with a friend. The patient has no complaints. She states she has been feeling well. Her knees are not hurting her at all anymore and she is not needing Bextra any longer. I think the last steroid injection that she had with Dr. XYZ really did help. The patient denies any shortness of breath or cough. Has no nausea, vomiting, abdominal pain. No diarrhea or constipation. She states her appetite is good. She clears her plate at noon. She has had no fevers, chills, or sweats. The friend with her states she is doing very well. Seems to eat excellently at noontime, despite this, the patient continues to lose weight. When I asked her what she eats for breakfast and for supper, she states she really does not eat anything. Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time. She states she is really not hungry the rest of the time except at lunchtime. She denies any fevers, chills, or sweats. We did do some lab work at the last office visit and CBC was essentially normal. Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3. This is fairly stable for her. Liver enzymes were normal. TSH was normal. Free albumin was normal at 23. She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS: ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:, No known drug allergies.,PAST MEDICAL HISTORY:, Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:, The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:, As above in HPI.,PHYSICAL EXAM:,General: This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face. States are clothes are fitting more loosely.,Vital Signs: Weight: 123, down 5 pounds from last month and down 11 pounds from May 2004. Blood pressure: 128/62. Pulse: 60. Respirations: 20. Temperature: 96.8.,Neck: Supple. Carotids are silent.,Chest: Clear to auscultation.,Cardiovascular: Regular rate and rhythm.,Abdomen: Soft and nontender, nondistended with positive bowel sounds. No organomegaly or masses are appreciated.,Extremities: Free of edema.,ASSESSMENT:,1. Unintentional weight loss. I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2. Depression, doing well.,3. Paranoia, doing well.,4. Dementia, stable.,5. Osteoarthritis of the knees, pain is much improved.,PLAN:,1. Continue on current medications.,2. I did call and talk with doctor at hospital. We discussed different options. We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time. Connie will weigh the patient once a week and I will go ahead and see the patient in one month. We can see how she is doing at that time. If she continues to lose weight despite eating better, then I think we will need to do further evaluation. ### Label: 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: ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:, Ms. ABC is a 57-year-old woman. She suffers from morbid obesity. She also has diabetes and obstructive sleep apnea. She was evaluated in the Bariatric Surgical Center for placement of a band. During her workup, she was noted to have evidence of cholelithiasis. It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band. The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438. She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS: ,To return to the Medifast diet. To continue with her blood glucose. She needs to follow up with Dr. B, and she will see me next week on Friday. We will determine if we will proceed with her lap band at that time. She may shower. She needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars. ### Label: Discharge Summary ### Response:

Discharge Summary