transcription,medical_specialty
"dobutamine stress echocardiogram,reason for exam: , chest discomfort, evaluation for coronary artery disease.,procedure in detail: , the patient was brought to the cardiac center.  cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  the patient maximized at 30 mcg/kg per minute.  images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,wall motion assessed at all levels as well as at recovery.,the patient got nauseated, had some mild shortness of breath.  no angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,the resting heart rate was 78 with the resting blood pressure 186/98.  heart rate reduced by the vasodilator effects of dobutamine to 130/80.  maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,the ekg at rest showed sinus rhythm with no st-t wave depression suggestive of ischemia or injury.  incomplete right bundle-branch block was seen.  the maximal stress test ekg showed sinus tachycardia.  there was subtle upsloping st depression in iii and avf, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no st elevation seen.,no ventricular tachycardia or ventricular ectopy seen during the test.  the heart rate recovered in a normal fashion after using metoprolol 5 mg.,the heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,the ef at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  all walls mentioned were augmented in a normal fashion.  at maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  ef improved to about 70%.,the wall motion score was unchanged.,impression:,1.  maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  negative ekg criteria for ischemia.,3.  normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  this is considered the negative dobutamine stress echocardiogram test, medical management.",32
"chief complaint: , i need refills.,history of present illness:,  the patient presents today stating that she needs refills on her xanax, and she would also like to get something to help her quit smoking.  she is a new patient today.  she states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain.  she states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office.  she states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about chantix and wanted to give it a try.,objective:  ,well developed and well nourished.  she does not appear to be in any acute distress.  cardiovascular:  regular rhythm.  no murmurs, gallops, or rubs.  capillary refill less than 3 seconds.  peripheral pulses are 2+ bilaterally.  respiratory:  her lungs are clear to auscultation bilaterally with good effort.  no tenderness to palpation over chest wall.  musculoskeletal:  she has full range of motion of all four extremities.  no tenderness to palpation over long bones.  skin:  warm and dry.  no rashes or lesions.  neuro:  alert and oriented x3.  cranial nerves ii-xii are grossly intact.  no focal deficits.,plan: , i did refill her medications.  i have requested that she have her primary doctor forward her records to me.  i have discussed chantix and its use and success rate.  she was given a prescription, as well as a coupon.  she is to watch for any worsening signs or symptoms.  she verbalized understanding of discharge instructions and prescriptions.  i would like to see her back to proceed with her preventive health measures.",24
"procedure note: , pacemaker icd interrogation.,history of present illness: , the patient is a 67-year-old gentleman who was admitted to the hospital.  he has had icd pacemaker implantation.  this is a st. jude medical model current drrs, 12345 pacemaker.,diagnosis: , severe nonischemic cardiomyopathy with prior ventricular tachycardia.,findings: , the patient is a ddd mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, r sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  the defibrillator portion is set at vt1 at 139 beats per minute with svt discrimination on therapy is monitor only.  vt2 detection criteria is 169 beats per minute with svt discrimination on therapy of atp times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  vf detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  the patient is in normal sinus rhythm.,impression:  ,normally functioning pacemaker icd post implant day number 1.",37
"preoperative diagnoses:,1.  clinical stage t2, nx, mx transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  new right hydronephrosis.,postoperative diagnoses:,1.  clinical stage t4a, n3, m1 transitional cell carcinoma of the urinary bladder, status post chemotherapy and radiation therapy.,2.  new right hydronephrosis.,3.  carcinoid tumor of the small bowel.,title of operation: , exploratory laparotomy, resection of small bowel lesion, biopsy of small bowel mesentery, bilateral extended pelvic and iliac lymphadenectomy (including preaortic and precaval, bilateral common iliac, presacral, bilateral external iliac lymph nodes), salvage radical cystoprostatectomy (very difficult due to previous chemotherapy and radiation therapy), and continent urinary diversion with an indiana pouch.,anesthesia: , general endotracheal and epidural.,indications: , this patient is a 65-year-old white male, who was diagnosed with a high-grade invasive bladder cancer in june 2005.  during the course of his workup of transurethral resection, he had a heart attack when he was taken off plavix after having had a drug-eluting stent placed in.  he recovered from this and then underwent chemotherapy and radiation therapy with a brief response documented by cystoscopy and biopsy after which he had another ischemic event.  the patient has been followed regularly by myself and dr. x and has been continuously free of diseases since that time.  in that interval, he had a coronary artery bypass graft and was taken off of plavix.  most recently, he had a pet ct, which showed new right hydronephrosis and a followup cystoscopy, which showed a new abnormality in the right side of his bladder where he previously had the tumor resected and treated.  i took him to the operating room and extensively resected this area with findings of a high-grade muscle invasive bladder cancer.  we could not identify the right ureteral orifice, and he had a right ureteral stent placed.  metastatic workup was negative and cardiology felt he was at satisfactory medical risk for surgery and he was taken to the operating room this time for planned salvage cystoprostatectomy.  he was interested in orthotopic neobladder, and i felt like that would be reasonable if resecting around the urethra indicated the tissue was healthier.  therefore, we planned on an indiana pouch continent cutaneous diversion.,operative findings:  ,on exploration, there were multiple abnormalities outside the bladder as follows:  there were at least three small lesions within the distal small bowel, the predominant one measured about 1.5 cm in diameter with a white scar on the surface.  there were two much smaller lesions also with a small white scar, with very little palpable mass.  the larger of the two was resected and found to be a carcinoid tumor.  there also were changes in the small bowel mesentry that looked inflammatory and biopsies of this showed only fibrous tissue and histiocytes.  the small bowel mesentry was fairly thickened at the base, but no discrete abnormality noted.,both common iliac and lymph node samples were very thickened and indurated, and frozen section of the left showed cancer cells that were somewhat degenerative suggesting a chemotherapy and radiation therapy effect; viability was unable to be determined.  there was a frozen section of the distal right external iliac lymph node that was negative.  the bladder was very thickened and abnormal suggesting extensive cancer penetrating just under the peritoneal surface.  the bladder was fairly stuck to the pelvic sidewall and anterior symphysis pubis requiring very meticulous resection in order to get it off of these structures.  the external iliac lymph nodes were resected on both sides of the obturator; the lymph packet, however, was very stuck and adherent to the pelvic sidewall, and i elected not to remove that.  the rest of the large bowel appeared normal.  there were no masses in the liver, and the gallbladder was surgically absent.  there was nasogastric tube in the stomach.,operative procedure in detail: , the patient was brought to the operative suite, and after adequate general endotracheal and epidural anesthesia obtained, having placed in the supine position and flexed over the anterior superior iliac spine, his abdomen and genitalia were sterilely prepped and draped in usual fashion.  the radiologist placed a radial arterial line and an intravenous catheter.  intravenous antibiotics were given for prophylaxis.  we made a generous midline skin incision from high end of the epigastrium down to the symphysis pubis, deepened through the rectus fascia, and the rectus muscles separated in the midline.  exploration was carried out with the findings described.  the bladder was adherent and did appear immobile.  moist wound towels and a bookwalter retractor was placed for exposure.  we began by assessing the small and large bowel with the findings in the small bowel as described.  we subsequently resected the largest of the lesions by exogenous wedge resection and reanastomosed the small bowel with a two-layer running 4-0 prolene suture.  we then mobilized the cecum and ascending colon and hepatic flexure after incising the white line of toldt and mobilized the terminal ileal mesentery up to the second and third portion of the duodenum.  the ureters were carefully dissected out and down deep in the true pelvis.  the right ureter was thickened and hydronephrotic with a stent in place and the left was of normal caliber.  i kept the ureters intact until we were moving the bladder off as described above.  at that point, we then ligated the ureters with the rp-45 vascular load and divided it.,we then established the proximal ____________ laterally to both genitofemoral nerves and resected the precaval and periaortic lymph nodes.  the common iliac lymph nodes remained stuck to the ureter.  frozen section with the findings described on the left.,i then began the dissection over the right external iliac artery and vein and had a great deal of difficulty dissecting distally.  i was, however, able to establish the distal plane of dissection and a large lymph node was present in the distal external iliac vessels.  clips were used to control the lymphatics distally.  these lymph nodes were sent for frozen section, which was negative.  we made no attempt to circumferentially mobilize the vessels, but essentially, swept the tissue off of the anterior surface and towards the bladder and then removed it.  the obturator nerve on the right side was sucked into the pelvic sidewall, and i elected not to remove those.  on the left side, things were a little bit more mobile in terms of the lymph nodes, but still the obturator lymph nodes were left intact.,we then worked on the lateral pedicles on both sides and essentially determined that i can take these down.  i then mobilized the later half of the symphysis pubis and pubic ramus to get distal to the apical prostate.  at this point, i scrubbed out of the operation, talked to the family, and indicated that i felt the cystectomy was more palliative than therapeutic, and i reiterated his desire to be free of any external appliance.,i then proceeded to take down the lateral pedicles with an rp-45 stapler on the right and clips distally.  the endopelvic fascia was incised.  i then turned my attention posteriorly and incised the peritoneum overlying the anterior rectal wall and ramus very meticulously dissected the rectum away from the posterior denonvilliers fascia.  i intentionally picked down those two pedicles lateral to the rectum between the clips and then turned my attention retropubically.  i was able to pass a 0 vicryl suture along the dorsal venous complex, tied this, and then, sealed and divided the complex with a ligasure and oversewed it distally with 2-0 vicryl figure-of-eight stitch.  i then divided the urethra distal to the apex of the prostate, divided the foley catheter between the clamps and then the posterior urethra.  i then was able to take down the remaining distal attachments of the apex and took the dissection off the rectum, and the specimen was then free of all attachments and handed off the operative field.  the bivalved prostate appeared normal.  we then carefully inspected the rectal wall and noted to be intact.  the wound was irrigated with 1 l of warm sterile water and a meticulous inspection made for hemostasis and a dry pack placed in the pelvis.,we then turned our attention to forming the indiana pouch.  i completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  the colon was divided proximal to the middle colic using a gia-80 stapler.  i then divided the avascular plane of treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  the mesentery was then sealed with a ligasure device and divided, and the bowel was divided with a gia-60 stapler.  we then performed a side-to-side ileo-transverse colostomy using a gia-80 stapler, closing the open end with a ta 60.  the angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,we then removed the staple line along the terminal ileum, passed a 12-french robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the gia-60 stapler.  the ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by rowland, et al, and following this, passage of an 18-french robinson catheter was associated with the characteristic ""pop,"" indicating that we had adequately plicated the ileocecal valve.,as the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  we then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 vicryl sutures.  the bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the sgia polysorb-75.  between the staple lines, vicryl sutures were placed and the defects closed with 3-0 vicryl suture ligatures.,we then turned our attention to forming the ileocolonic anastomosis.  the left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 vicryl sutures, and this was stented with a cook 8.4-french ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  the right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  we then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  a 24-french malecot catheter was placed through the cecum and secured with a chromic suture.  the staple lines were then buried with a running 3-0 vicryl two-layer suture and the open end of the pouch closed with a ta 60 polysorb suture.  the pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,we then made a final inspection for hemostasis.  the cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  we then matured our stoma through the umbilicus.  we removed the plug of skin through the umbilicus and delivered the ileal segment through this.  a portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  we left an 18-french robinson through the stoma and secured this to the skin with silk sutures.  the malecot and stents were also secured in a similar fashion.,the stoma was returned to the umbilicus after resecting the terminal ileum.,we then placed a large jp drain into both obturator fossae and brought it up the right lower quadrant.  rectus fascia was closed with buried #2 prolene stitch anchoring a new figure of 8 at each end tying the two stitches above and in the middle and underneath the fascia.  interrupted stitches were placed as well.  the subcutaneous tissue was irrigated and skin closed with surgical clips.  the estimated blood loss was 2500 ml.  the patient received 5 units of packed red blood cells and 4 units of ffp.  the patient was then awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.",38
"procedure in detail: , after written consent was obtained from the patient, the patient was brought back into the operating room and identified.  the patient was placed in the operating room table in supine position and given general anesthetic.,ancef 1 g was given for infectious prophylaxis.  once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  through the lateral portal, the camera was placed.  through the medial portal, tools were placed.  we proceeded to examine scarring of the patellofemoral joint.  then we probed the patellofemoral joint.  a chondroplasty was performed using a shaver.  then we moved down to the lateral gutter.  some loose bodies were found using a shaver and dissection.  we moved down the medial gutter.  no plica was found.,we moved into the medial joint; we found that the medial meniscus was intact.  we moved to the lateral joint and found that the lateral meniscus was intact.  pictures were taken.  we drained the knee and washed out the knee with copious amounts of sterile saline solution.  the instruments were removed.  the 2 portals were closed using 3-0 nylon suture.  xeroform, 4 x 4s, kerlix x2, and ted stocking were placed.  the patient was successfully extubated and brought to the recovery room in stable condition.  i then spoke with the family going over the case, postoperative instructions, and followup care.",26
"preoperative diagnoses:,1.  bunion left foot.,2.  hammertoe, left second toe.,postoperative diagnoses:,1.  bunion left foot.,2.  hammertoe, left second toe.,procedure performed:,1.  bunionectomy, scarf type, with metatarsal osteotomy and internal screw fixation, left.,2.  arthroplasty left second toe.,history:  ,this 39-year-old female presents to abcd general hospital with the above chief complaint.  the patient states that she has had bunion for many months.  it has been progressively getting more painful at this time.  the patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,procedure: , an iv was instituted by the department of anesthesia in the preop holding area.  the patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  copious amount of webril were placed around the left ankle followed by a blood pressure cuff.  after adequate sedation was achieved by the department of anesthesia, a total of 15 cc of 0.5% marcaine plain was injected in a mayo and digital block to the left foot.  the foot was then prepped and draped in the usual sterile orthopedic fashion.  the foot was elevated from the operating table and exsanguinated with an esmarch bandage.  the pneumatic ankle tourniquet was inflated to 250 mmhg and the foot was lowered to the operating table.  the stockinette was reflected.  the foot was cleansed with wet and dry sponge.  attention was then directed to the first metatarsophalangeal joint of the left foot.  an incision was created over this area approximately 6 cm in length.  the incision was deepened with a #15 blade.  all vessels encountered were ligated for hemostasis.  the skin and subcutaneous tissue was then dissected from the capsule.  care was taken to preserve the neurovascular bundle.  dorsal linear capsular incision was then created.  the capsule was then reflected from the head of the first metatarsal.  attention was then directed to the first interspace where a lateral release was performed.  a combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  a lateral capsulotomy was performed.  attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  the incision was then extended proximally with further dissection down to the level of the bone.  two 0.45 k-wires were then inserted as access guides for the scarf osteotomy.  a standard scarf osteotomy was then performed.  the head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  after adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 k-wire.  a 3.0 x 12 mm screw was then inserted in the standard ao fashion with compression noted.  a second 3.0 x 14 mm screw was also inserted with tight compression noted.  the remaining prominent medial eminence medially was then resected with a sagittal saw.  reciprocating rasps were then used to smooth any sharp bony edges.  the temporary fixation wires were then removed.  the screws were again checked for tightness, which was noted.  attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  a straight stat was used to assist in removing a portion of the capsule.  the capsule was then reapproximated with #2-0 vicryl medially.  dorsal capsule was then reapproximated with #3-0 vicryl in a running fashion.  the subcutaneous closure was performed with #4-0 vicryl followed by running subcuticular stitch with #5-0 vicryl.  the skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,attention was then directed to the left second toe.  a dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  the incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  an incision was made on either side of the extensor digitorum longus tendon.  a curved mosquito stat was then used to reflex the tendon laterally.  the joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  a sagittal saw was then used to resect the head of the proximal head.  the bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  the extensor digitorum longus tendon was inspected and noted to be intact.  any sharp edges were then smoothed with reciprocating rasp.  the area was then flushed with copious amounts of sterile saline.  the skin was then reapproximated with #4-0 nylon.  dressings consisted of owen silk, 4x4s, kling, kerlix, and coban.  pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  the patient tolerated the above procedure and anesthesia well without complications.  the patient was transported to pacu with vital signs stable and vascular status intact to the left foot.  the patient is to follow up with dr. x in his clinic as directed.",26
"preoperative diagnosis: , colovesical fistula.,postoperative diagnoses:,1.  colovesical fistula.,2.  intraperitoneal abscess.,procedure performed:,1.  exploratory laparotomy.,2.  low anterior colon resection.,3.  flexible colonoscopy.,4.  transverse loop colostomy and jp placement.,anesthesia: , general.,history:  ,this 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  the patient had retrograde cystogram, which revealed colovesical fistula.  recommendation for a surgery was made.  the patient was explained the risks and benefits as well as the two sons and the daughter.  they understood that the patient can even die from this procedure.  all the three procedures were explained, without a colostomy, with hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the hartmann's colostomy leaving the anastomosis with the risk of leaking.,procedure details: , the patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  an incision was performed in the midline below the umbilicus to the pubis with a #10 blade bard parker.  electrocautery was used for hemostasis down to the fascia.  the fascia was grasped with ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  at this point, immediately a small bowel was retracted cephalad.  the patient was taken to a slightly trendelenburg position and the descending colon was seen.  the white line of toldt was opened all the way down to the area of inflammation.  at this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  when the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  the abscess was cultured and sent it back to bacteriology department and immediately the opening into the bladder was visualized.  at this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  at this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  immediately, a gia was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a ta-55 balloon roticulator was fired.  the specimen was cut with #10 blade bard-parker and sent it to pathology.  immediately copious amount of irrigation was used and the staple line in the descending colon was brought with allis.  a pursestring device was fired.  the staple line was cut.  the dilators were used using #25 and #29, then _________ #29 eea was placed and the suture was tied.  at this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 ethicon gia was introduced.  the spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,immediately, the eea was connected with a mushroom.  it was tied, fired, and a doyen was placed above the anastomosis approximately four inches.  fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  no air was seen evolving from the staple line.  all fluid was removed and pictures of the staple line were taken.  the scope was removed at this point.  the case was passed to dr. x for repair of the vesicle fistula.  dr. x did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  after this was performed, copious amount of irrigation was used again.  more lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  the incision was performed in the right upper quadrant.,this incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  the wire was passed under the transverse colon.  it was left in place.  moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a jp was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  at this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop pds suture and then tied.  electrocautery for hemostasis and the subcutaneous tissue.  copious amount of irrigation was used.  the skin was approximated with staples.  at this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  the colostomy was opened longitudinally and then matured with interrupted #3-0 vicryl suture through the skin edge.  one it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  as previously mentioned, the penrose was removed and the bard was secured with a #3-0 nylon suture.  the jp was secured with #3-0 nylon suture as well.  at this point, dressings were applied.  the patient tolerated the procedure well.  the stent from the left ureter was removed and the foley was left in place.  the patient did tolerate the procedure well and will be followed up during the hospitalization.",14
"preoperative diagnosis:  ,carcinoma of the prostate, clinical stage t1c.,postoperative diagnosis: , carcinoma of the prostate, clinical stage t1c.,title of operation: , cystoscopy, cryosurgical ablation of the prostate.,findings:  ,after measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone.  because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,operation in detail: , the patient was brought to the operating room and placed in the supine position.  after adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position.  full bowel prep had been obtained prior to the procedure.  after performing flexible cystoscopy, a foley catheter was placed per urethra into the bladder.  next, the ultrasound probe was placed into the stabilizer and advanced into the rectum.  an excellent ultrasound image was visualized of the entire prostate, which was re-measured.  next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement.  then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate.  ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra.  repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed.  the cms urethral warmer was then passed per urethra into the bladder, and flow instituted.  after placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior.  the ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself.  active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature.  the urethral warmer was left on after the needles were removed and the patient brought to the recovery room.  the patient tolerated the procedure well and left the operating room in stable condition.",37
"chief complaint:,  dental pain.,history of present illness:,  this is a 27-year-old female who presents with a couple of days history of some dental pain.  she has had increasing swelling and pain to the left lower mandible area today.  presents now for evaluation.,past medical history: , remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  she has chronic pain in general and is followed by dr. x.,review of systems: , otherwise, unremarkable.  has not noted any fever or chills.  however she, as mentioned, does note the dental discomfort with increasing swelling and pain.  otherwise, unremarkable except as noted.,current medications: , please see list.,allergies: , iodine, fish oil, flexeril, betadine.,physical examination: , vital signs:  the patient was afebrile, has stable and normal vital signs.  the patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  heent:  unremarkable.  i do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  there is no neck adenopathy.  oral mucosa is moist and well hydrated.  dentition looks to be in reasonable condition.  however, she definitely is tender to percussion on the left lower first premolar.  i do not see any huge cavity or anything like that.  no real significant gingival swelling and there is no drainage noted.  none of the teeth are tender to percussion.,procedure:,  dental nerve block.  using 0.5% marcaine with epinephrine, i performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  i have then written a prescription for penicillin and vicodin for pain.,impression: , acute dental abscess.,assessment and plan:  ,the patient needs to follow up with the dentist for definitive treatment and care.  she is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  however, outpatient followup should be adequate.  she is discharged in stable condition.",5
"consult request for:, medical management.,the patient has been in special procedures now for over 2 hours and i am unable to examine.,history of present illness:, obtained from dr. a on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. she was unfortunately outside of the window for emergent treatment and had a negative ct scan of the head. was started on protocol medication and that is similar to tpa, which is an investigational study.,during the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. her heart rate was 130. she was brought down with cardizem. she received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as tpa has no obvious known association with this.,at that time the patient became comatose and required emergent intubation and paralyzation. her diastolic at that time rose up to 190, likely the result of the acute second stroke. she is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. dr. a has updated the family to her extremely guarded and critical prognosis.,at present, it is not known yet, we do not have the stat echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,review of systems:, complete review of systems is unobtainable at present. from what i can tell, is that she is scheduled for an upcoming bladder distension surgery and i do not know if this is why she is off coumadin for chronic afib or what, at this point. tremor for 3-4 years, diagnosed as early parkinson's.,past medical history:, gerd, hypertension times 20 years, arthritis, parkinson's, tia, chronic atrial fibrillation, on coumadin three years.,past surgical history:, cholecystectomy, tah 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,allergies:, morphine, sulfas (rash), prozac.,medications at home: lanoxin 0.25 daily; inderal la 80 daily; mobic 7.5 daily; robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen prn; darvocet-n 100 prn.,social history:, she does not drink or smoke. lives in fayetteville, tennessee.,family history:, mother died of cancer, unknown type. dad died of an mi.,vaccination status: unknown.,physical examination:,vital signs: on arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,general: she was apparently alert and able to give history on arrival. currently do not have any available vital signs or physical exam, as i cannot get to the patient.,laboratory: ,reviewed and are remarkable for white count of 13 with 76 neutrophils. bmp is normal, except for a blood sugar of 157, hemoglobin a1c is pending. tsh 2.1, cholesterol 165, digoxin 1.24, cpk 57. abg 7.47/32/459 on 100%. magnesium 1.5. esr 9, coags normal.,ekg is pending my review.,chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,chest x-ray, shoulder films and ct scan of the head: i have reviewed. chest x-ray has good et tube placement. she has mild cardiomegaly. some mild interstitial opacities consistent with ogd and minimal amount of atherosclerosis of the aorta.,ct scan of the head: i do not see any active bleeding.,x-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,assessment/plan/problems:,1. large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. obviously she is in critical condition and stable with multiple strokes. one must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. we need stat records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. i have ordered a stat echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a pfo we may be able to better prognosticate at this point. obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by dr. a and interventional radiology.,2. hypertension/atrial fibrillation: this will be a difficult management and the fact that she has been on a beta-blocker for parkinson's, she may have withdrawal to the beta-blockers as we remove this. given her atrial fibrillation, i do agree the safest agent right now is to use a cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. also, would use it to control the atrial fibrillation. we would, however, be very cautious not to put her in heart block with the digoxin and the beta-blocker on board. weighing all risks and benefits, i think that given the fact that she has a beta-blocker on board and digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. if, however, we run into trouble with this, i would prefer to switch her to brevibloc or an esmolol drip and see how she does, as she may withdraw from the beta-blocker. i will be watching this closely and managing the hypertension as i see fit at the moment, based on all factors. will also ask cardiology if she has one that sees her here, to help guide this. her digoxin level is appropriate, as well as a tsh. i do not feel that we need to work this up further, other than the stat echo and ultrasound of the leg.,3. respiratory failure requiring ventilator: i have discussed this with dr. devlin, we do not feel the need to hyperventilate her at present. we will keep her comfortable on the breathing machine and try to keep her ph in a normal range, around 7.4, and her co2 in the 30 to 40 range. if she has brain swelling, we will need to hyperventilate her to a pco2 of 30 and a ph of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. optimize electrolytes as you can.,5. deep vein thrombosis prophylaxis for now, with thigh-high ted hose, possibly scds, although i do not have experience with the vampire/venom to know if we need to worry about dic which the scds may worsen. will follow daily cbcs for that.,6. nutrition: will go ahead and start a low dose of tube feeds and hope that she does survive.,i will defer all updates to the family for the next 24 to 48 hours to dr. devlin's expertise, given her unknown and fluctuating neurologic prognosis.,thank you so much for allowing us to participate in her care. we will be happy to do all medication treatment until the point that i feel that i would need any help from critical care. i believe that we will be able to manage her fully at this point, for simplicity sake.",5
"the right eardrum is intact showing a successful tympanoplasty.  i cleaned a little wax from the external meatus.  the right eardrum might be very slightly red but not obviously infected.  the left eardrum (not the surgical ear) has a definite infection with a reddened bulging drum but no perforation or granulation tissue.  also some wax at the external meatus i cleaned with a q-tip with peroxide.  the patient has no medical allergies.  since he recently had a course of omnicef we chose to put him on augmentin (i checked and we did not have samples), so i phoned in a two-week course of augmentin 400 mg chewable twice daily with food at walgreens.  i looked at this throat which looks clear.  the nose only has a little clear mucinous secretions.  if there is any ear drainage, please use the floxin drops.  i asked mom to have the family doctor (or dad, or me) check the ears again in about two weeks from now to be sure there is no residual infection.  i plan to see the patient again later this spring.",24
"preoperative diagnosis: , postmenopausal bleeding.,postoperative diagnosis: , same.,operation performed:  ,fractional dilatation and curettage.,specimens: , endocervical curettings, endometrial curettings.,indications for procedure: , the patient recently presented with postmenopausal bleeding.  an office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,findings: , examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  the uterine cavity was smooth upon curettage.  curettings were fairly copious.  sounding depth was 8 cm.,procedure:,  the patient was brought to the operating room with an iv in place.  the patient was given a general anesthetic and was placed in the lithotomy position.  examination under anesthesia was completed with findings as noted.  she was prepped and draped and a speculum was placed into the vagina.  ,tenaculum was placed on the cervix.  the endocervical canal was curetted using a kevorkian curette, and the sound was used to measure the overall depth of the uterus.  the endocervical canal was dilated without difficulty to a size 16 french dilator.  a small, sharp curette was passed into the uterine cavity and curettings were obtained.,after completion of the curettage, polyp forceps were passed into the uterine cavity.  no additional tissue was obtained.  upon completion of the dilatation and curettage, minimum blood loss was noted.,the patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.",23
"multisystem exam,constitutional: , the vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  the patient appeared alert.,eyes: , the conjunctiva was clear.  the pupil was equal and reactive.  there was no ptosis.  the irides appeared normal.,ears, nose and throat: , the ears and the nose appeared normal in appearance.  hearing was grossly intact.  the oropharynx showed that the mucosa was moist.  there was no lesion that i could see in the palate, tongue. tonsil or posterior pharynx.,neck: , the neck was supple.  the thyroid gland was not enlarged by palpation.,respiratory:  ,the patient's respiratory effort was normal.  auscultation of the lung showed it to be clear with good air movement.,cardiovascular: , auscultation of the heart revealed s1 and s2 with regular rate with no murmur noted.  the extremities showed no edema.,breasts:  ,breast inspection showed them to be symmetrical with no nipple discharge.  palpation of the breasts and axilla revealed no obvious mass that i could appreciate.,gastrointestinal:  ,the abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  bowel sounds were present.,gu:  ,the external genitalia appeared to be normal.  the pelvic exam revealed no adnexal masses.  the uterus appeared to be normal in size and there was no cervical motion tenderness.,lymphatic:  ,there was no appreciated node that i could feel in the groin or neck area.,musculoskeletal:  ,the head and neck by inspection showed no obvious deformity.  again, the extremities showed no obvious deformity.  range of motion appeared to be normal for the upper and lower extremities.,skin:,  inspection of the skin and subcutaneous tissues appeared to be normal.  the skin was pink, warm and dry to touch.,neurologic: , deep tendon reflexes were symmetrical at the patellar area.  sensation was grossly intact by touch.,psychiatric:  ,the patient was oriented to time, place and person.  the patient's judgment and insight appeared to be normal.",24
"preoperative diagnosis: , benign prostatic hypertrophy.,postoperative diagnosis: , benign prostatic hypertrophy.,surgery:  ,cystopyelogram and laser vaporization of the prostate.,anesthesia: , spinal.,estimated blood loss: , minimal.,fluids: , crystalloid.,brief history: , the patient is a 67-year-old male with a history of turp, presented to us with urgency, frequency, and dribbling.  the patient was started on alpha-blockers with some help, but had nocturia q.1h.  the patient was given anticholinergics with minimal to no help.  the patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate.  at this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream.  continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed.  the patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,the patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder.  the patient was told that he may need anticholinergics.  there could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,procedure in detail:  ,the patient was brought to the or and anesthesia was applied.  the patient was placed in dorsal lithotomy position.  the patient was given preoperative antibiotics.  the patient was prepped and draped in the usual sterile fashion.  a #23-french scope was inserted inside the urethra into the bladder under direct vision.  bilateral pyelograms were normal.  the rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder.  there was enlargement of the lateral lobes of the prostate.  the old tur scar was visualized right at the bladder neck.  using diode side-firing fiber, the lateral lobes were taken down.  the verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure.  pictures were taken and were shown to the family.  at the end of the procedure, there was good hemostasis.  a total of about 15 to 20 minutes of lasering time was used.  a #22 3-way catheter was placed.  at the end of the procedure, the patient was brought to recovery in stable condition.  plan was for removal of the foley catheter in 48 hours and continuation of use of anticholinergics at night.",37
"history of present illness:,  a 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  she is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  she continues to have some left-sided jaw pain.  denies any headache, fever, cough, or sore throat.  she had used cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  she has also had problems with sinusitis in the past and chronic left-sided headache.,family history:,  reviewed and unchanged.,allergies: , to cephalexin.,current medications:,  ibuprofen.,social history:,  she is a nonsmoker.,review of systems:,  as above.  no nausea, vomiting, or diarrhea.,physical examination:,general:  a well-developed and well-nourished female, conscious, alert, and in no acute distress.,vital signs:  weight:  121 pounds.  temperature:  97.9 degrees.,skin:  reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,eyes:  perrla.  conjunctivae are clear.,ears:  left tm with some effusion.  right tm is clear.  canals are clear.  external auricles are nontender to manipulation.,nose:  nasal mucosa is pink and moist without discharge.,throat:  nonerythematous.  no tonsillar hypertrophy or exudate.,neck:  supple without adenopathy or thyromegaly.,lungs:  clear.  respirations are regular and unlabored.,heart:  regular rate and rhythm at rate of 100 beats per minute.,assessment:,1.  serous otitis.,2.  atopic dermatitis.,plan:,1.  nasacort aq two sprays each nostril daily.,2.  duraphen ii one b.i.d.,3.  refills cutivate cream 0.05% to apply to affected areas b.i.d.  recheck p.r.n.",15
"physical examination,general:  ,the patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  no dysarthria is noted.  no discomfort on presentation is noted.,head: , atraumatic, normocephalic.  pupils are equal, round and reactive to light.  extraocular muscles are intact.  sclerae are white without injection or icterus.  fundi are without papilledema, hemorrhages or exudates with normal vessels.,ears:  ,the ear canals are patent without edema, exudate or drainage.  tympanic membranes are intact with a normal cone of light.  no bulging or erythema to indicate infection is present.  there is no hemotympanum.  hearing is grossly intact.,nose: , without deformity, bleeding or discharge.  no septal hematoma is noted.,oral cavity: , no swelling or abnormality to the lip or teeth.  oral mucosa is pink and moist.  no swelling to the palate or pharynx.  uvula is midline.  the pharynx is without exudate or erythema.  no edema is seen of the tonsils.  the airway is completely patent.  the voice is normal.  no stridor is heard.,neck: , no signs of meningismus.  no brudzinski or kernig sign is present.  no adenopathy is noted.  no jvd is seen.  no bruits are auscultated.  trachea is midline.,chest: , symmetrical with equal breath sounds.  equal excursion.  no hyperresonance or dullness to percussion is noted.  there is no tenderness on palpation of the chest.,lungs: , clear to auscultation bilaterally.  no rales, rhonchi or wheezes are appreciated.  good air movement is auscultated in all 4 lung fields.,heart: , regular rate and rhythm.  no murmur.  no s3, s4 or rub is auscultated.  point of maximal impulse is strong and in normal position.  abdominal aorta is not palpable.  the carotid upstroke is normal.,abdomen: , soft, nontender and nondistended.  normal bowel sounds are auscultated.  no organomegaly is appreciated.  no masses are palpated.  no tympany is noted on percussion.  no guarding, rigidity or rebound tenderness is seen on exam.  murphy and mcburney sign is negative.  there is no rovsing, obturator or psoas sign present.  no hepatosplenomegaly and no hernias are noted.,rectal: , normal tone.  no masses.  soft, brown stool in the vault.  guaiac negative.,genitourinary: , external genitalia without erythema, exudate or discharge.  vaginal vault is without discharge.  cervix is of normal color without lesion.  the os is closed.  there is no bleeding noted.  uterus is noted to be of normal size and nontender.  no cervical motion tenderness is seen.  no masses are palpated.  the adnexa are without masses or tenderness.,extremities: , no clubbing, cyanosis or edema.  pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  no deformity or signs of trauma.  all joints are stable without laxity.  there is good range of motion of all joints without tenderness or discomfort.  homan sign is negative.  no atrophy or contractures are noted.,skin: , no rashes.  no jaundice.  pink and warm with good turgor.  good color.  no erythema or nodules noted.  no petechia, bulla or ecchymosis.,neurologic: , cranial nerves ii through xii are grossly intact.  muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  babinski is downgoing bilaterally.  sensation is intact to light touch and vibration.  gait is normal.  romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  there is no ataxia seen on gait testing.  tone is normal.  no pronator drift is seen.,psychiatric:  ,the patient is oriented x4.  mood and affect are appropriate.  memory is intact with good short- and long-term memory recall.  no dysarthria is noted.  remote memory is intact.  judgment and insight appear normal.",15
"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.",21
"reason for admission: , hepatic encephalopathy.,history of present illness: , the patient is a 51-year-old native american male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  he said that he was doing fine prior to that and denied having any complaints.  he was sitting watching tv and he felt sleepy.  so, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  his head hit the toilet seat.  then, he started having bleeding and had pain in the area with headache.  he did not lose consciousness as far as he can tell.  he went and woke up his sister.  this happened somewhere between 10:30 and 11 p.m.  his sister brought a towel and covered the laceration on the back of his head and called ems, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a ct of the head was obtained and ruled out any acute intracranial pathology.  on his lab work, his ammonia was found to be markedly elevated at 106.  so, he is being admitted for management of this.  he denied having any abdominal pain, change in bowel habits, gi bleed, hematemesis, melena, or hematochezia.  he said he has been taking his medicines, but he could not recall those.  he denied having any symptoms prior to this fall.  he said earlier today he also fell.  he also said that this was an accidental fall caused by problem with his walker.  he landed on his back at that time, but did not have any back pain afterwards.,past medical history:,1.  liver cirrhosis caused by alcohol.  this is per the patient.,2.  he thinks he is diabetic.,3.  history of intracranial hemorrhage.  he said it was subdural hematoma.  this was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  he said he had a seizure back then, but he does not have seizures now.,past surgical history:,1.  he has a surgery on his stomach as a child.  he does not know the type.,2.  surgery for a leg fracture.,3.  craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,medications: , he does not remember his medications except for the lactulose and multivitamins.,allergies: , dilantin.,social history: , he lives in sacaton with his sister.  he is separated from his wife who lives in coolidge.  he smokes one or two cigarettes a day.  denies drug abuse.  he used to be a heavy drinker, quit alcohol one year ago and does not work currently.,family history:,  negative for any liver disease.,review of systems:,general:  denies fever or chills.  he said he was in gilbert about couple of weeks ago for fever and was admitted there for two days.  he does not know the details.,ent:  no visual changes.  no runny nose.  no sore throat.,cardiovascular:  no syncope, chest pain, or palpitations.,respiratory:  no cough or hemoptysis.  no dyspnea.,gi:  no abdominal pain.  no nausea or vomiting.  no gi bleed.  history of alcoholic liver disease.,gu:  no dysuria, hematuria, frequency, or urgency.,musculoskeletal:  denies any acute joint pain or swelling.,skin:  no new skin rashes or itching.,cns:  had a seizure many years ago with no recurrences.  left-sided hemiparesis after subdural hematoma from a fight/trauma.,endocrine:  he thinks he has diabetes but does not know if he is on any diabetic treatment.,physical examination:,vital signs:  temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,general:  the patient is lying in bed, appears comfortable, very pleasant native american male in no apparent distress.,heent:  his skull has a scar on the left side from previous surgery.  on the back of his head, there is a laceration, which has two staples on.  it is still oozing minimally.  it is tender.  no other traumatic injury is noted.  eyes, pupils react to light.  sclerae anicteric.  nostrils are normal.  oral cavity is clear with no thrush or exudate.,neck:  supple.  trachea midline.  no jvd.  no thyromegaly.,lymphatics:  no cervical or supraclavicular lymphadenopathy.,lungs:  clear to auscultation bilaterally.,heart:  normal s1 and s2.  no murmurs or gallops.  regular rate and rhythm.,abdomen:  soft, distended, nontender.  no organomegaly or masses.,lower extremities:  +1 edema bilaterally.  pulses strong bilaterally.  no skin ulcerations noted.  no erythema.,skin:  several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,back:  no tenderness by exam.,rectal:  no masses.  no abscess.  no rectal fissures.  guaiac was performed by me and it was negative.,neurologic:  he is alert and oriented x2.  he is slow to some extent in his response.  no asterixis.  right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  increased tone noted in upper and lower extremities on the right compared to the left.  deep tendon reflexes are +3 on the right and +2 on the left.  muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  the upper extremity is +4/5.  lower extremity is 3/5.  the left side has a normal strength.  sensation appears to be intact.  babinski is upward on the right, equivocal on the left.,psychiatric:  flat affect.  mood appeared to be appropriate.  no active hallucinations or psychotic symptoms.,laboratory data: ",12
"discharge diagnosis:  ,complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,additional discharge diagnoses:,1.  chronic pain.,2.  tobacco use.,3.  history of hepatitis c.,reason for admission:,  the patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  he has had prolonged hospitalizations because of this problem.  he was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  examination in the emergency room revealed significant concern for significant cellulitis.  decision was made to admit him to the hospital.,hospital course:,  the patient was admitted on 03/26/08 and was started on iv antibiotics elevation, was also counseled to minimizing the cigarette smoking.  the patient had edema of his bilateral lower extremities.  the hospital consult was also obtained to address edema issue question was related to his liver hepatitis c.  hospital consult was obtained.  this included an ultrasound of his abdomen, which showed just mild cirrhosis.  his leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  the patient eventually grew mrsa in a moderate amount.  he was treated with iv vancomycin.  local wound care and elevation.  the patient had slow progress.  he was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  the patient was thought safe to discharge home.,discharge instructions: , the patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  he was also given prescription for percocet and oxycontin, picked up at my office.  he is instructed to do daily wound care and also wrap his leg with an ace wrap.  followup was arranged in a couple of weeks.,discharge condition: , stable.",10
"preoperative diagnosis: , abdominal mass.,postoperative diagnosis: , abdominal mass.,procedure:,  paracentesis.,description of procedure:  ,this 64-year-old female has stage ii endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  at the present time, the patient is under radiation treatment.  two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  we proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  the cytology of the fluid was negative and the culture was also negative.  eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat cat scan of the abdomen and pelvis.,the cat scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  therefore, i called the patient home and she came to the emergency department where the service was provided.  at that time, i proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  unfortunately, the catheter was open.  i did not have a drainage system at that time.  so, i withdrew directly with a syringe 700 ml of clear fluid.  the system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  she was given an appointment to see me in the office next monday, which is three days from now.",14
"medications:,  none.,description of the procedure:,  after informed consent was obtained, the patient was placed in the left lateral decubitus position and the olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  the mucosa appeared normal.  retroflex examination of the rectum was normal.",14
"history and clinical data:  ,the patient is an 88-year-old gentleman followed by dr. x, his primary care physician, dr. y for the indication of cll and dr. z for his cardiovascular issues.  he presents to the care center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,he reports no clear-cut chest discomfort or difficulty with angina.  he has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of cva, tia, nor peripheral vascular claudication.,review of systems:,  general review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  he reports no fever, shaking chills, nothing supportive of gi or gu blood loss, no productive or nonproductive cough.,past medical history:,  remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, copd, single vessel coronary disease, esophageal reflux, cll, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,social history: , remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,medications at home:,  include, lortab 7.5 mg up to three times daily for chronic arthritic discomfort, miacalcin nasal spray once daily, omeprazole 20 mg daily, diovan 320 mg daily, combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to tekturna 150 mg daily, zoloft 25 mg daily.,allergies:  ,he has known history of allergy to clonidine, medifast does fatigue.,diagnostic and laboratory data: , chest x-ray upon presentation to the ellis emergency room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,a 12-lead ekg, sinus rhythm at a rate of 68 per minute, right bundle-branch block type ivcv with moderate nonspecific st changes.  low voltage in the limb leads.,wbc 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  low serum sodium at 132, potassium 4, bun 28, creatinine 1.2, random glucose 179.  low total protein 5.7.  magnesium level 2.3, troponin 0.404 with the b-natriuretic peptide of 8200.,physical examination:  ,he is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  jvd difficult to assess.  normal carotids with obvious bruits.  conjunctivae pink.  oropharynx clear.  mild kyphosis.  diffusely depressed breath sounds halfway up both posterior lung fields.  no active wheezing.  cardiac exam:  regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  abdomen:  soft, nontender, protuberant, benign.  extremities:  2+ bilateral pitting edema to the level of the knees.  neuro exam:  appears alert, oriented x3.  appropriate manner and affect, exceedingly hard of hearing.,overall impression:,  an 88-year-old white male with the following major medical issues:,1.  presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  hypertension with suboptimal controlled currently.,3.  diabetes.,4.  prostate ca, status post radium seed implant.,5.  copd, on metered-dose inhaler.,6.  cll followed by dr. y.,7.  single-vessel coronary disease, no recent anginal quality chest pain, no changes in ecg suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  hearing loss, anxiety.,9.  significant degenerative joint disease.,plan:,1.  admit to a4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  strict i&o, foley catheter has already been placed.,3.  daily bmp.,4.  two-dimensional echocardiogram to assess left ventricular systolic function.  serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  further recommendations will be forthcoming pending his clinical course and hospital.",15
"current history:,  a 94-year-old female from the nursing home with several days of lethargy and anorexia.  she was found to have evidence of uti.  she also has renal insufficiency and digitalis toxicity.  she is admitted for further treatment.,past medical history, social history, family history, physical examination can be seen on the admission h&p.,laboratories on admission: , white count 11,700, hemoglobin 12.8, hematocrit 37.2, bun 91, creatinine 2.2, sodium 131, potassium 5.1.  digoxin level of 4.1.,hospital course: , the patient was admitted and intravenous fluids and antibiotics were administered.  blood cultures were negative.  urine cultures were nondiagnostic.  renal function improved with creatinine down to 1 at the time of discharge.  digoxin was restarted at a lower dose.  her condition improved and she is stabilized and transferred back to assisted living in good condition.,primary diagnoses:,1.  urinary tract infection.,2.  volume depletion.,3.  renal insufficiency.,4.  digitalis toxicity.,secondary diagnoses:,1.  aortic valve stenosis.,2.  congestive heart failure.,3.  hypertension.,4.  chronic anemia.,5.  degenerative joint disease.,6.  gastroesophageal reflux disease.,procedures:,  none.,complications: , none.,discharge condition: , improved and stable.,discharge plan:  ,physical activity:  with assistance.  ,diet:  no restriction.  ,medications:  lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, augmentin 875 mg 1 tablet twice a day for 1 week, nexium 40 mg daily, elavil 10 mg at bedtime, detrol 2 mg twice a day, potassium 10 meq daily and diclofenac 50 mg twice a day.  ,follow up:  she will see dr. x in the office as scheduled.",10
"preoperative diagnoses,1.  cervical spinal stenosis, c3-c4 and c4-c5.,2.  cervical spondylotic myelopathy.,postoperative diagnoses,1.  cervical spinal stenosis, c3-c4 and c4-c5.,2.  cervical spondylotic myelopathy.,operative procedures,1.  radical anterior discectomy, c3-c4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (cpt 63075).,2.  radical anterior discectomy c4-c5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (cpt 63076).,3.  anterior cervical fusion, c3-c4 (cpt 22554),4.  anterior cervical fusion, c4-c5 (cpt 22585).,5.  utilization of allograft for purposes of spinal fusion (cpt 20931).,6.  application of anterior cervical locking plate c3-c5 (cpt 22845).,anesthesia:,  general endotracheal.,complications: , none.,estimated blood loss:  ,250 cc.,operative indications:  ,the patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness.  his mri confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness.  we discussed the diagnosis and the treatment options.  due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, i recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections.  i explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at c3-c4 and c4-c5.  we reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal.  furthermore i explained that the fusion may not become solid or that the hardware could break.  we discussed various techniques available for obtaining fusion and i recommended allograft and plate fixation.  i explained the rationale for this as well as the options of using his own bone.  furthermore, i explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,operative technique: , after obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications.  he was then positioned supine on the operating table, and all bony prominences were padded.  pulse oximetry was maintained on both feet throughout the case.  the arms were carefully padded and tucked at his sides.  a roll was placed between the shoulder blades.  the areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion.  ten pounds of traction was applied.  a needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision.  the entire neck was then sterilely prepped and draped in the usual fashion.,a transverse skin incision was made and carried down to the platysma muscle.  this was then split in line with its fibers.  blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized.  a needle was placed into a disc and an x-ray was done to determine its location.  the longus colli muscles were then elevated bilaterally with the electrocautery unit.  self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,radical anterior discectomies were performed at c3-c4 and c4-c5.  this included complete removal of the anterior annulus, nucleus, and posterior annulus.  the posterior longitudinal ligament was removed as were the posterior osteophytes.  foraminotomies were then accomplished bilaterally.  once all of this was accomplished, the blunt-tip probe was used to check for any residual compression.  the central canal was wide open at each level as were the foramen.,a high-speed bur was used to remove the cartilaginous endplates above and below each interspace.  bleeding cancellous bone was exposed.  the disc spaces were measured and appropriate size allografts were placed sterilely onto the field.  after further shaping of the grafts with the high-speed bur, they were carefully impacted in to position.  there was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace.  all weight was then removed from the crania tongs.,the appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis.  two screws were then placed into each of the vertebral bodies at c3, c4, and c5.  there was excellent purchase.  a final x-ray was done confirming good position of the hardware and grafts.  the locking screws were then applied, also with excellent purchase.,following a final copious irrigation, there was good hemostasis and no dural leaks.  the carotid pulse was strong.  a drain was placed deep to the level of the platysma muscle and left at the level of the hardware.  the wounds were then closed in layers using 4-0 vicryl suture for the platysma muscle, 4-0 vicryl suture for the subcutaneous tissue, and 4-0 vicryl suture in a subcuticular skin closure.  steri-strips were placed followed by application of a sterile dressing.  the drain was hooked to bulb suction.  a philadelphia collar was applied.,the cranial tongs were carefully removed.  the soft tissue overlying the puncture site was massaged to free it up from the underlying bone.  there was good hemostasis.,the patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.",37
"history of present illness: , patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  she has had a dry cough and a fever as high as 100, but this has not been since the first day.  she denies any vomiting or diarrhea.  she did try some tylenol cough and cold followed by tylenol cough and cold severe, but she does not think that this has helped.,family history: , the patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,review of systems:,  the patient does note some pressure in her sinuses.  she denies any skin rash.,social history:,  patient lives with her mother, who is here with her.,nursing notes were reviewed with which i agree.,physical examination,vital signs:  temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  room air oximetry is 100%.,general:  patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,heent:  head is normocephalic, atraumatic.  pharynx shows no erythema, tonsillar edema, or exudate.  both tms are easily visualized and are clear with good light reflex and no erythema.  sinuses do show some mild tenderness to percussion.,neck:  no meningismus or enlarged anterior/posterior cervical lymph nodes.,heart:  regular rate and rhythm without murmurs, rubs, or gallops.,lungs:  clear without rales, rhonchi, or wheezes.,skin:  no rash.,assessment:,  viral upper respiratory infection (uri) with sinus and eustachian congestion.,plan:,  i did educate the patient about her problem and urged her to switch to advil cold & sinus for the next three to five days for better control of her sinus and eustachian discomfort.  i did urge her to use afrin nasal spray for the next three to five days to further decongest her sinuses.  if she is unimproved in five days, follow up with her pcp for re-exam.",5
"procedure performed: , colonoscopy and biopsy.,indications:,  the patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  she has had problems with recurrent seizures and has been seen by dr. xyz, who started her recently on methadone.,medications: , fentanyl 200 mcg, versed 10 mg, phenergan 25 mg intravenously given throughout the procedure.,instrument: , pcf-160l.,procedure report: , informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon.,a colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  the distal ileum was examined, which was normal in appearance.  random biopsies were obtained from the ileum and placed in jar #1.  random biopsies were obtained from the normal-appearing colon and placed in jar #2.  small internal hemorrhoids were noted within the rectum on retroflexion.,complications: , none.,assessment:,1.  small internal hemorrhoids.,2.  ileal colonic anastomosis seen in the proximal transverse colon.,3.  otherwise normal colonoscopy and ileum examination.,plan:, followup results of biopsies.  if the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it's okay with dr. xyz, for treatment of her chronic abdominal pains.",37
"procedure:,  cervical epidural steroid injection without fluoroscopy.,anesthesia: , local sedation.,vital signs: , see nurse's notes.,complications: , none.,details of procedure: , int was placed.  the patient was in the sitting position.  the posterior neck and upper back were prepped with betadine.  lidocaine 1.5% was used for skin wheal made between c7-t1 ________.  an 18-gauge tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted.  after negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg depo-medrol was injected.  neosporin and band-aid were applied over the site. the patient discharged to recovery room in stable condition.",27
"postoperative diagnosis:  fever.,procedures:  bronchoalveolar lavage.,indications for procedure:  the patient is a 28-year-old male, status post abdominal trauma, splenic laceration, and splenectomy performed at the outside hospital, who was admitted to the trauma intensive care unit on the evening of august 4, 2008.  greater than 24 hours postoperative, the patient began to run a fever in excess of 102.  therefore, evaluation of his airway for possible bacterial infection was performed using bronchoalveolar lavage.,description of procedure:  the patient was preoxygenated with 100% fio2 for approximately 5 to 10 minutes prior to the procedure.  the correct patient and procedure was identified by time out by all members of the team.  the patient was prepped and draped in a sterile fashion and sterile technique was used to connect the bal lavage catheter to lukens trap suction.  a catheter was introduced into the endotracheal tube through a t connector and five successive 20 ml aliquots of normal saline were flushed through the catheter, each time suctioning out the sample into the lukens trap.  a total volume of 30 to 40 ml was collected in the trap and sent to the lab for quantitative bacteriology.  the patient tolerated the procedure well and had no episodes of desaturation, apnea, or cardiac arrhythmia.  a postoperative chest x-ray was obtained.",37
"preoperative diagnosis: , adenotonsillar hypertrophy and chronic otitis media.,postoperative diagnosis:,  adenotonsillar hypertrophy and chronic otitis media.,procedure performed:,1.  tympanostomy and tube placement.,2.  adenoidectomy.,anesthesia:  ,general endotracheal.,description of procedure:  ,the patient was taken to the operating room, prepped and draped in the usual fashion.  after induction of general endotracheal anesthesia, the mcivor mouth gag was placed in the oral cavity and a tongue depressor applied.  two #12-french red rubber robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,attention was directed to the nasopharynx.  with the bovie set at 50 coag and the suction bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior.  the mcivor was relaxed and attention was then directed to the ears.,the left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,an anteroinferior quadrant tympanostomy incision was made.  fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the rosen needle.  cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,by a similar procedure, the opposite tympanostomy and tube placement were accomplished.,the patient tolerated the procedure well and left the operating room in good condition.",11
"preoperative diagnosis: , left testicular torsion, possibly detorsion.,postoperative diagnosis: , left testicular torsion, possibly detorsion.,procedure: , left scrotal exploration with detorsion.  already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,anesthetic:,  a 0.25% marcaine local wound insufflation per surgeon, 15 ml of toradol.,findings:,  congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally.  no testis necrosis.,estimated blood loss:,  5 ml.,fluids received: , 300 ml of crystalloid.,tubes and drains:,  none.,specimens: , no tissues sent to pathology.,counts:,  sponges and needle counts were correct x2.,indications of operation: , the patient is a 4-year-old boy with abrupt onset of left testicular pain.  he has had a history of similar onset.  apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, i recommended an exploration.,description of operation:,  the patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified.  once he was anesthetized, he was placed in supine position and sterilely prepped and draped.  superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery.  electrocautery was used for hemostasis.  the subdartos pouch was created with curved tenotomy scissors.  the tunica vaginalis was then delivered, incised, and testis was delivered.  the testis itself with a bell-clapper deformity.  there was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord.  the penis fascia was cauterized and subdartos pouch was created.  the upper aspect of fascia was then closed with pursestring suture of 4-0 chromic.  the testis was then placed into the scrotum in a proper orientation.  no tacking sutures within the testis itself were used.  the tunica vaginalis; however, was wrapped perfectly behind the back of the testis.  a similar procedure was performed on the right side.  again, an appendix testis was cauterized.  no torsion was seen.  he also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture.  the local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% marcaine.  the scrotal wall was then closed with subcuticular closure of #4-0 chromic.  dermabond tissue adhesive was then used.  the patient tolerated the procedure well.  he was given iv toradol and was taken to the recovery room in stable condition.",37
"diagnosis:,  polycythemia vera with secondary myelofibrosis.,reason for visit:, followup of the above condition.,chief complaint: , left shin pain.,history of present illness: , a 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis.  diagnosis was made some time in 2005/2006.  initially, he underwent phlebotomy.  he subsequently transferred his care here.  in the past, he has been on hydroxyurea and interferon but did not tolerate both of them.  he is jak-2 positive.  he does not have any siblings for a match-related transplant.  he was seen for consideration of a mud transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health.,at our institution, the patient received a trial of lenalidomide and prednisone for a short period.  he did well with the combination.  subsequently, he developed intolerance to lenalidomide.  he complained of severe fatigue and diarrhea.  this was subsequently stopped.,the patient reports some injury to his left leg last week.  his left leg apparently was swollen.  he took steroids for about 3 days and stopped.  left leg swelling has disappeared.  the patient denies any other complaints at this point in time.  he admits to smoking marijuana.  he says this gives him a great appetite and he has actually gained some weight.  performance status in the ecog scale is 1.,physical examination:,vital signs:  he is afebrile.  blood pressure 144/85, pulse 86, weight 61.8 kg, and respiratory rate 18 per minute.  general:  he is in no acute distress.  heent:  there is no pallor, icterus or cervical adenopathy that is noted.  oral cavity is normal to exam.  chest:  clear to auscultation.  cardiovascular:  s1 and s2 normal with regular rate and rhythm.  abdomen:  soft and nontender with no hepatomegaly.  spleen is palpable 4 fingerbreadths below the left costal margin.  there is no guarding, tenderness, rebound or rigidity noted.  bowel sounds are present.  extremities:  reveal no edema.  palpation of the left tibia revealed some mild tenderness.  however, i do not palpate any bony abnormalities.  there is no history of deep venous thrombosis.,laboratory data: , cbc from today is significant for a white count of 41,900 with an absolute neutrophil count of 34,400, hemoglobin 14.8 with an mcv of 56.7, and platelet count 235,000.,assessment and plan:,1.  jak-2 positive myeloproliferative disorder.  the patient has failed pretty much all available options.  he is not a candidate for chlorambucil or radioactive phosphorus because of his young age and the concern for secondary malignancy.  i have e-mailed dr. x to see whether he will be a candidate for the lbh trial.  hopefully, we can get a jak-2 inhibitor trial quickly on board.,2.  i am concerned about the risk of thrombosis with his elevated white count.  he is on aspirin prophylaxis.  the patient has been told to call me with any complaints.,3.  left shin pain.  i have ordered x-rays of the left tibia and knee today.  the patient will return to the clinic in 3 weeks.  he is to call me in the interim for any problems.",16
"chief complaint: , ""a lot has been thrown at me."",the patient is interviewed with husband in room.,history of present illness: , this is a 69-year-old caucasian woman with a history of huntington disease, who presented to hospital four days ago after an overdose of about 30 haldol tablets 5 mg each and tylenol tablet 325 mg each, 40 tablets.  she has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  the patient states she had been thinking about suicide for a couple of weeks.  felt that her huntington disease had worsened and she wanted to spare her family and husband from trouble.  reports she has been not socializing with her family because of her worsening depression.  husband notes that on monday after speaking to dr. x, they had been advised to alternate the patient's pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  they did as they have instructed and husband feels this may have had some factor on her worsening depression.  the patient decided to ingest the pills when her husband went to work on friday.  she thought friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  her husband left around 7 in the morning and returned around 11 and found her sleeping.  about 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,she says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the huntington gene.  she does not clearly explain how this has made her suicidality subside.,this is the third suicide attempt in the last two months for this patient.  about two months ago, the patient took an overdose of tylenol and some other medication, which the husband and the patient are not able to recall.  she was taken to southwest memorial hermann hospital.  a few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  husband locked the gun after that and she was taken to bellaire hospital.  the patient has had three psychiatric admissions in the past two months, two to southwest memorial and one to bellaire hospital for 10 days.  she sees dr. x once or twice weekly.  he started seeing her after her first suicide attempt.,the patient's husband and the patient state that until march 2009, the patient was independent, was driving herself around and was socially active.  since then she has had worsening of her huntington symptoms including short-term memory loss.  at present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  the patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her huntington disease.,the patient's mother passed away 25 years ago from huntington's.  her grandmother passed away 50 years ago and two brothers also passed away of huntington's.  the patient has told her husband that she does not want to go that way.  the patient denies auditory or visual hallucinations, denies paranoid ideation.  the husband and the patient deny any history of manic or hypomanic symptoms in the past.,past psychiatric history: , as per the hpi, this is her third suicide attempt in the last two months and started seeing dr. x.  she has a remote history of being on lexapro for depression.,medications: , her medications on admission, alprazolam 0.5 mg p.o. b.i.d., artane 2 mg p.o. b.i.d., haldol 2.5 mg p.o. t.i.d., norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  husband has stated that the patient's chorea becomes better when she takes haldol.  alprazolam helps her with anxiety symptoms.,past medical history: , huntington disease, symptoms of dementia and hypertension.  she has an upcoming appointment with the neurologist.  currently, does have a primary care physician and _______ having an outpatient psychiatrist, dr. x, and her current neurologist, dr. y.,allergies: , codeine and keflex.,family medical history:  ,strong family history for huntington disease as per the hpi.  mother and grandmother died of huntington disease.  two young brothers also had huntington disease.,family psychiatric history: , the patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,social history:  ,the patient lives with her husband of 48 years.  she used to be employed as a registered nurse.  her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  she rarely drinks socially.  she denies any illicit substance usage.  her husband reportedly gives her medication daily.  has been proactive in terms of seeking mental health care and medical care.  the patient and husband report that from march 2009, she has been relatively independent, more socially active.,mental status exam:  ,this is an elderly woman appearing stated age.  alert and oriented x4 with poor eye contact.  appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  she is cooperative.  her speech is of low volume and slow rate and rhythm.  her mood is sad.  her affect is constricted.  her thought process is logical and goal-directed.  her thought content is negative for current suicidal ideation.  no homicidal ideation.  no auditory or visual hallucinations.  no command auditory hallucinations.  no paranoia.  insight and judgment are fair and intact.,laboratory data:,  a ct of the brain without contrast, without any definite evidence of acute intracranial abnormality.  u-tox positive for amphetamines and tricyclic antidepressants.  acetaminophen level 206.7, alcohol level 0.  the patient had a leukocytosis with white blood cell of 15.51, initially tsh 1.67, t4 10.4.,assessment: , this is a 69-year-old white woman with huntington disease, who presents with the third suicide attempt in the past two months.  she took 30 tablets of haldol and 40 tablets of tylenol.  at present, the patient is without suicidal ideation.  she reports that her worsening depression has coincided with her worsening huntington disease.  she is more hopeful today, feels that she may be able to get help with her depression.,the patient was admitted four days ago to the medical floor and has subsequently been stabilized.  her liver function tests are within normal limits.,axis i:  major depressive disorder due to huntington disease, severe.  cognitive disorder, nos.,axis ii:  deferred.,axis iii:  hypertension, huntington disease, status post overdose.,axis iv:  chronic medical illness.,axis v:  30.,plan,1.  safety.  the patient would be admitted on a voluntary basis to main-7 north.  she will be placed on every 15-minute checks with suicidal precautions.,2.  primary psychiatric issues/medical issues.  the patient will be restarted as per written by the consult service for prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, haldol 2 mg p.o. q.8h., artane 2 mg p.o. daily, xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  substance abuse.  no acute concern for alcohol or benzo withdrawal.,4.  psychosocial.  team will update and involve family as necessary.,disposition: , the patient will be admitted for evaluation, observation, treatment.  she will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  we will place occupational therapy consult and social work consults.",21
"preoperative diagnoses:,1.  left spermatocele.,2.  family planning.,postoperative diagnoses:,1.  left spermatocele.,2.  family planning.,procedure performed:,1.  left spermatocelectomy/epididymectomy.,2.  bilateral partial vasectomy.,anesthesia: , general.,estimated blood loss:,  minimal.,specimen: , left-sided spermatocele, epididymis, and bilateral partial vasectomy.,disposition:  ,to pacu in stable condition.,indications and findings: , this is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  the patient also has family status complete and desired infertility.  the patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,findings: , at this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,description of procedure:,  after informed consent was obtained, the patient was moved to the operating room.  a general anesthesia was induced by the department of anesthesia.,the patient was prepped and draped in the normal sterile fashion for a scrotal approach.  a #15 blade was used to make a transverse incision on the left hemiscrotum.  electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  the left testicle was examined.  a large spermatocele was noted.  metzenbaum scissors were used to dissect the tissue around the left spermatocele.  once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  electrocautery was used to confirm excellent hemostasis.  attention was then turned to the more proximal aspect of the cord.  the vas deferens was palpated and dissected free with metzenbaum scissors.  hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  testicle was placed back in the scrotum in appropriate anatomic position.  the dartos tissue was closed with running #3-0 vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  attention was then turned to the right side.  the vas was palpated in the scrotum.  a small skin incision was made with a #15 blade and the vas was grasped with a small allis clamp and brought into the surgical field.  a scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  two ends were hemostated with hemostats and divided with metzenbaum scissors.  lumen was coagulated with electrocautery.  silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  a #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  the patient was sent to recovery in stable condition.  he was given prescriptions for doxycycline 100 mg b.i.d., for five days and vicodin es 1 p.o. q.4h. p.r.n., pain, #30 for pain.  the patient is to followup with dr. x in seven days.",37
"preoperative diagnoses:,1.  senile nuclear cataract, left eye.,2.  senile cortical cataract, left eye., ,postoperative diagnoses:,1.  senile nuclear cataract, left eye.,2.  senile cortical cataract, left eye., ,procedures: , phacoemulsification of cataract, extraocular lens implant in left eye., ,lens implant used:,  alcon, model sn60wf, power of 22.5 diopters., ,phacoemulsification time:,  1 minute 41 seconds at 44.4% power., ,indications for procedure: , this patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40.  the patient complains of difficulties with glare in performing activities of daily living.,informed consent:,  the risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery.  all questions from the patient were answered after the surgical procedure was explained in detail.  the risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc.  alternative of the procedure is to do nothing or seek a second opinion.  informed consent for this procedure was obtained from the patient.,operative technique: , the patient was brought to the holding area.  previously, an intravenous infusion was begun at a keep vein open rate.  after adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye.  a total of 10 ml mixture with a 70/30 mixture of 2% xylocaine without epinephrine and 0.75% bupivacaine without epinephrine.  an adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area.  manual pressure and a honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted.  vital sign monitors were detached from the patient.  the patient was moved to the operative suite and the same monitors were reattached.  the periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery.  the speculum was set into place and the operative microscope was brought over the eye.  the eye was examined.  adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,a temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea.  then a pocket incision was created without entering the anterior chamber of the eye.  two peripheral paracentesis ports were created on each side of the initial incision site.  viscoelastic was used to deepen the anterior chamber of the eye.  a 2.65 mm keratome was then used to complete the corneal valve incision.  a cystitome was bent and created using a tuberculin syringe needle.  it was placed in the anterior chamber of the eye.  a continuous curvilinear capsulorrhexis was begun.  it was completed using o'gawa utrata forceps.  a balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus.  the lens nucleus was noted to be freely mobile in the bag.,the phacoemulsification tip was placed into the anterior chamber of the eye.  the lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique.  all remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports.  the posterior capsule remained intact throughout the entire procedure.  provisc was used to deepen the anterior chamber of the eye.  a crescent blade was used to expand the internal aspect of the wound.  the lens was taken from its container and inspected.  no defects were found.  the lens power selected was compared with the surgery worksheet from dr. x's office.  the lens was placed in an inserter under provisc.  it was placed through the wound, into the capsular bag and extruded gently from the inserter.  it was noted to be adequately centered in the capsular bag using a sinskey hook.  the remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique.  the eye was noted to be inflated without overinflation.  the wounds were tested for leaks, none were found.  five drops dilute betadine solution was placed over the eye.  the eye was irrigated.  the speculum was removed.  the drapes were removed.  the periocular area was cleaned and dried.  maxitrol ophthalmic ointment was placed into the interpalpebral space.  a semi-pressure patch and shield was placed over the eye.  the patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with dr. x tomorrow morning in the office.",25
"admission diagnoses:  ,fracture of the right femoral neck, also history of alzheimer's dementia, and hypothyroidism.,discharge diagnoses: , fracture of the right femoral neck, also history of alzheimer's dementia, hypothyroidism, and status post hemiarthroplasty of the hip.,procedure performed:  ,hemiarthroplasty, right hip.,consultations:  ,medicine for management of multiple medical problems including alzheimer's.,hospital course: , the patient was admitted on 08/06/2007 after a fall with subsequent fracture of the right hip.  the patient was admitted to orthopedics and consulted medicine.  the patient was actually taken to the operating room, consent signed by durable power of attorney, taken on 08/06/2007, had right hip hemiarthroplasty, recovered without incidence.  the patient had continued confusion and dementia, which is apparently his baseline secondary to his alzheimer's.  brief elevation of white count following the surgery, which did subside.  studies, ua and blood culture were negative.  the patient was stable and was discharged to heartland.,condition on discharge: , stable.,discharge instructions:,  transfer to abc for rehab and continued care.  diabetic diet.  activity, ambulate as tolerated with posterior hip precautions.  rehab potential fair.  he will need nursing, social work, pt/ot, and nutrition consults.  resume home meds, dvt prophylaxis, aspirin, and compression stockings.  follow up dr. x in one to two weeks; call 123-4567 for an appointment.",10
"flexible bronchoscopy,the flexible bronchoscopy is performed under conscious sedation in the pediatric intensive care unit.  i explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  a bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  the sample will then be sent for testing.  the flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,the parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  a booklet containing the description of the procedure and other information was provided.",3
"chief complaint:, left foot pain.,history:, xyz is a basketball player for university of houston who sustained an injury the day prior. they were traveling. he came down on another player's foot sustaining what he describes as an inversion injury. swelling and pain onset immediately. he was taped but was able to continue playing he was examined by john houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. he has been in a walking boot. he has been taped firmly. pain with weightbearing activities. he is limping a bit. no significant foot injuries in the past. most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,physical exam:, he does have some swelling from the hindfoot out toward the midfoot. his arch is maintained. his motion at the ankle and subtalar joints is preserved. forefoot motion is intact. he has pain with adduction and abduction across the hindfoot. most of this discomfort is laterally. his motor strength is grossly intact. his sensation is intact, and his pulses are palpable and strong. his ankle is not tender. he has minimal to no tenderness over the atfl. he has no medial tenderness along the deltoid or the medial malleolus. his anterior drawer is solid. his external rotation stress is not painful at the ankle. his tarsometatarsal joints, specifically 1, 2 and 3, are nontender. his maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. some tenderness over the dorsolateral side of the talonavicular joint as well. the medial talonavicular joint is not tender.,radiographs:, those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. i don't see a definite fracture. the tarsometarsal joints are anatomically aligned. radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. review of an mr scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. also some changes along the dorsal talonavicular joint. i don't see any significant marrow edema or definitive fracture line. ,impression:,  left chopart joint sprain.,plan:,  i have spoken to xyz about this. continue with ice and boot for weightbearing activities. we will start him on a functional rehab program and progress him back to activities when his symptoms allow. he is clear on the prolonged duration of recovery for these hindfoot type injuries.",5
"chief complaint:,  the patient is here for two-month followup.,history of present illness:,  the patient is a 55-year-old caucasian female.  she has hypertension.  she has had no difficulties with chest pain.  she has some shortness of breath only at walking up the stairs.  she has occasional lightheadedness only if she bends over then stands up quickly.  she has had no nausea, vomiting, or diarrhea.  she does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with dr. xyz in january of this coming year.  the patient is wanting to lose weight before her surgery.  she is concerned about possible coronary disease or stroke risk.  she has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable.  she has had fairly normal lipid panel, last being checked on 11/26/2003.  cholesterol was 194, triglycerides 118, hdl 41, and ldl 129.  the patient is a nonsmoker.  her fasting glucose in november 2003 was within normal limits at 94.  her fasting insulin level was normal.  repeat nonfasting glucose was 109 on 06/22/2004.  she does not have history of diabetes.  she does not exercise regularly and is not able to because of knee pain.  she also has had difficulties with low back pain.  x-ray of the low back did show a mild compression fracture of l1.  she has had no falls that would contribute to a compression fracture.  she has had a normal dexa scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on dexa scan.  she is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,current medications:,  hydrochlorothiazide 12.5 mg a day, prozac 20 mg a day, vioxx 25 mg a day, vitamin c 250 mg daily, vitamin e three to four tablets daily, calcium with d 1500 mg daily, multivitamin daily, aspirin 81 mg daily, monopril 40 mg daily, celexa p.r.n.,allergies:  ,bactrim, which causes nausea and vomiting, and adhesive tape.,past medical history:,1.  hypertension.,2.  depression.,3.  myofascitis of the feet.,4.  severe osteoarthritis of the knee.,5.  removal of the melanoma from the right thigh in 1984.,6.  breast biopsy in january of 1997, which was benign.,7.  history of holter monitor showing ectopic beat.  echocardiogram was normal.  these were in 1998.,8.  compression fracture of l1, unknown cause.  she had had no injury.  interestingly, dexa scan was normal 11/07/2003, which is somewhat conflicting.,social history:,  the patient is married.  she is a nonsmoker and nondrinker.,review of systems:,  as per the hpi.,physical examination:,general:  this is a well-developed, well-nourished, pleasant caucasian female, who is overweight.,vital signs:  weight:  refused.  blood pressure:  148/82, on recheck by myself with a large cuff, it was 125/60.  pulse:  64.  respirations:  20.  temperature:  96.3.,neck:  supple.  carotids are silent.,chest:  clear to auscultation.,cardiovascular:  revealed a regular rate and rhythm without murmur, s3, or s4.,extremities:  revealed no edema.,neurologic:  grossly intact.,radiology:  ekg revealed normal sinus rhythm, rate 61, borderline first degree av block, and poor r-wave progression in the anterior leads.,assessment:,1.  hypertension, well controlled.,2.  family history of cerebrovascular accident.,3.  compression fracture of l1, mild.,4.  osteoarthritis of the knee.,5.  mildly abnormal chest x-ray.,plan:,1.  we will get a c-reactive protein cardiac.,2.  we discussed weight loss options.  i would recommend weight watchers or possibly having her see a dietician.  she will think about these options.  she is not able to exercise regularly right now because of knee pain.,3.  we would recommend a screening colonoscopy.  she states that we discussed this in the past and she canceled her appointment to have that done.  she will go ahead and make an appointment to see dr. xyz for screening colonoscopy.,4.  we will start fosamax 70 mg once weekly.  she is to take this in the morning on an empty stomach with full glass of water.  she is not to eat, lie down, or take other medications for at least 30 minutes after taking fosamax.,5.  i would like to see her back in one to two months.  at that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal ekg for preoperative cardiac testing.  one would also consider preoperative beta-blocker for cardiac protection.",34
"general: , vital signs and temperature as documented in nursing notes.  the patient appears stated age and is adequately developed.,eyes:,  pupils are equal, round, reactive to light and accommodation.  lids and conjunctivae reveal no gross abnormality.,ent:  ,hearing appears adequate.  no obvious asymmetry or deformity of the ears and nose.,neck: , trachea midline.  symmetric with no obvious deformity or mass; no thyromegaly evident.,respiratory:,  the patient has normal and symmetric respiratory effort.  lungs are clear to auscultation.,cardiovascular: , s1, s2 without significant murmur.,abdomen: , abdomen is flat, soft, nontender.  bowel sounds are active.  no masses or pulsations present.,extremities: , extremities reveal no remarkable dependent edema or varicosities.,musculoskeletal:  ,the patient is ambulatory with normal and symmetric gait.  there is adequate range of motion without significant pain or deformity.,skin: , essentially clear with no significant rash or lesions.  adequate skin turgor.,neurological: , no acute focal neurologic changes.,psychiatric:,  mental status, judgment and affect are grossly intact and normal for age.",24
"chief complaint: , abdominal pain.,history of present illness: , this is an 86-year-old female who is a patient of dr. x, who was transferred from abcd home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday.  during evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis.,past medical history:,  significant for dementia of alzheimer type, anxiety, osteoarthritis, and hypertension.,allergies: , the patient is allergic to pollens.,medications: , include alprazolam 0.5 mg b.i.d. p.r.n., mirtazapine 30 mg p.o. daily, aricept 10 mg p.o. nightly, namenda 10 mg p.o. b.i.d., benicar 40 mg p.o. daily, and claritin 10 mg daily p.r.n.,family history: , not available.,personal history:  ,not available.,social history:  ,not available.  the patient lives at a skilled nursing facility.,review of systems:  ,she has moderate-to-severe dementia and is unable to give any information about history or review of systems.,physical examination:,general:  she is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress.,vital signs:  temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air.,heent:  atraumatic.  pupils are equal and reactive to light.  sclerae and conjunctivae are normal.  throat without any pharyngeal inflammation or exudate.  oral mucosa is normal.,neck:  no jugular venous distention.  carotids are felt normally.  no bruit appreciated.  thyroid gland is not palpable.  there are no palpable lymph nodes in the neck or the supraclavicular region.,heart:  s1 and s2 are heard normally.  no murmur appreciated.,lungs:  clear to auscultation.,abdomen:  soft, diffusely tender.  no rebound or rigidity.  bowel sounds are heard.  most of the tenderness is located in the epigastric region.,extremities:  without any pedal edema, normal dorsalis pedis pulsations bilaterally.,breasts:  normal.,back:  the patient does not have any decubitus or skin changes on her back.,labs done at the time of admission: , wbc of 24.3, hemoglobin and hematocrit 15.3 and 46.5, mcv 89.3, and platelet count of 236,000.  pt 10.9, inr 1.1, ptt of 22.  urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria.  sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, bun 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, alt 121, ast 166, amylase 1797, and lipase over 3000.  x-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes.  ct of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis.  ultrasound of the abdomen revealed echogenic liver with fatty infiltration.  repeat cbc from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands.  sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, alt 314, ast 382, amylase 918, and lipase 1331.  the cultures are pending at this time.  ekg shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted.  troponin 0.004 and myoglobin is 39.6.,assessment:,1.  acute pancreatitis.,2.  leukocytosis.,3.  urinary tract infection.,4.  hyponatremia.,5.  dementia.,6.  anxiety.,7.  history of hypertension.,8.  abnormal electrocardiogram.,9.  osteoarthrosis.,plan:,  admit the patient to medical floor, npo, iv antibiotics, iv fluids, hold p.o. medications, gi consult, pain control, zofran iv p.r.n., bedrest, dvt prophylaxis, check blood and urine cultures.  i have left a message for the patient's son to call me back.",5
"subjective: , the patient is a 60-year-old female, who complained of coughing during meals.  her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  the patient had a history of hypertension and tia/stroke.  the patient denied history of heartburn and/or gastroesophageal reflux disorder.  a modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,objective: , modified barium swallow study was performed in the radiology suite in cooperation with dr. abc.  the patient was seated upright in a video imaging chair throughout this assessment.  to evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,assessment,oral stage:,  premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,pharyngeal stage: , no aspiration was observed during this evaluation.  penetration was noted with cup sips of thin liquid only.  trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  the patient's hyolaryngeal elevation and anterior movement are within functional limits.  epiglottic inversion is within functional limits.,cervical esophageal stage:  ,the patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,diagnostic impression:,  no aspiration was noted during this evaluation.  penetration with cup sips of thin liquid.  the patient did cough during this evaluation, but that was noted related to aspiration or penetration.,prognostic impression: ,based on this evaluation, the prognosis for swallowing and safety is good.,plan: , based on this evaluation and following recommendations are being made:,1.  the patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  the patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  the patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,the patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.",14
"preoperative diagnosis:,  end-stage renal disease with need for a long-term hemodialysis access.,postoperative diagnosis: , end-stage renal disease with need for a long-term hemodialysis access.,procedure: , right basilic vein transposition.,anesthesia:  ,general endotracheal.,estimated blood loss: , minimal.,complications: , none.,findings:,  excellent flow through fistula following the procedure.,statement of medical necessity:  ,the patient is a 68-year-old black female who recently underwent a brachiobasilic av fistula, but without transposition.  she has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  after discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,procedure in detail:  ,the patient was taken to the operating room, placed supine on the operating table.  after adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  a longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  the sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  this was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  the basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  there was noted to be excellent flow through the vein.  a pocket was then created just lateral to the incision in the subcutaneous tissue.  the vein was then placed into this pocket securing with multiple interrupted 3-0 vicryl sutures.  the bed of dissection of the basilic vein was then treated with fibrin sealant.  the subcutaneous tissue was then reapproximated with 3-0 vicryl sutures in interrupted fashion.  the skin was closed using 4-0 monocryl suture for a subcuticular stitch.  dermabond was applied to the incision.  again, there was noted to be good palpable thrill throughout the superficialized vein.  the patient was then awakened, and taken to the recovery room in stable condition.",20
"chief complaint: , chest pain.,history of present illness:,  the patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,the patient is diabetic and has a prior history of coronary artery disease.  the patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  the severity of the pain has progressively increased.  he describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  he ranks the pain a 7 on a scale of 1-10.  he admits some shortness of breath & diaphoresis.  he states that he has had nausea & 3 episodes of vomiting tonight.  he denies any fever or chills.  he admits prior episodes of similar pain prior to his ptca in 1995.  he states the pain is somewhat worse with walking and seems to be relieved with rest.  there is no change in pain with positioning.  he states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  the patient ranks his present pain a 4 on a scale of 1-10.  the most recent episode of pain has lasted one-hour.,the patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,review of systems:,  all other systems reviewed & are negative.,past medical history:,  diabetes mellitus type ii, hypertension, coronary artery disease, atrial fibrillation, status post ptca in 1995 by dr. abc.,social history: , denies alcohol or drugs.  smokes 2 packs of cigarettes per day.  works as a banker.,family history: , positive for coronary artery disease (father & brother).,medications: , aspirin 81 milligrams qday.  humulin n. insulin 50 units in a.m.  hctz 50 mg qday.  nitroglycerin 1/150 sublingually prn chest pain.,allergies: , penicillin.,physical exam: , the patient is a 40-year-old white male.,general:  the patient is moderately obese but he is otherwise well developed & well nourished.  he appears in moderate discomfort but there is no evidence of distress.  he is alert, and oriented to person place and circumstance.  there is no evidence of respiratory distress.  the patient ambulates",3
"reason for visit: , ms. abc is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation.  she comes to clinic by herself.,history of present illness:,  she has been followed for her hydrocephalus since 2002.  she also had an anterior cervical corpectomy and fusion from c3 though c5 in march 2007.  she was last seen by us in clinic in march 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0.  we wanted her to followup with dr. xyz regarding the mri of the cervical spine.  today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes.  she reports no urgency, incontinence, and feels that she completely empties her bladder when she goes.  she does experience some leakage with coughing.  she wears the pad on a daily basis.  she does not think that her bladder has changed much since we saw her last.  with respect to her thinking and memory, she reports no problems at this time.  she reports no headaches at this time.  with respect to her walking and balance, she says that it feels worse.  in the beginning of may, she had a coughing spell and at that time she developed buttock pain, which travels down the legs.  she states that her leg often feel like elastic and she experiences a tingling radiculopathy.  she says that this tingling is constant and at times painful.  she feels that she is walking slower for this reason.  she does not use the cane at this time.  most of the time, she is able to walk over uneven surfaces.  she is able to walk up and down stairs and has no trouble getting in and out of a car.,medications:,  rhinocort 32 mg two sprays a day, singulair 10 mg once a day, xyzal 5 mg in the morning, spiriva once a day, advair twice a day, prevacid 30 mg twice a day, os-cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,major findings:,  on exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty.  she is well developed, well nourished, and kempt.,the shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,mental status:  assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  her mini-mental status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,cranial nerves:  extraocular movements are somewhat inhibited.  she does not display any nystagmus at this time.  facial movement, hearing, head turning, tongue, and palate movement are all intact.,gait:  assessed using the tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,assessment:,  ms. abc has been experiencing difficulty with walking over the past several months.,problems/diagnoses:,1.  hydrocephalus.,2.  cervical stenosis and retrolisthesis.,3.  neuropathy in the legs.,plan: , before we recommend anything more, we would like to get a hold of the notes from dr. xyz to try to come up with a concrete plan as to what we can do next for ms. abc.  we believe that her walking is most likely not being effected by the hydrocephalus.  we would like to see her back in clinic in two and a half months or so.  we also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one.  i suggested that she use the cane at her on discretion.",21
"cc:, dysarthria,hx: ,this 52y/o rhf was transferred from a local hospital to uihc on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. she was a belted passenger in a car struck at a stop. there was no reported head or neck injury or alteration of consciousness. she was treated and released from a local er the same day. her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. in 4/94 she developed stress urinary incontinence which spontaneously resolved in june. in 8/94, her ha changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. she also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. in 9/94 she was evaluated by a local physician. examination then revealed incoordination, generalized fatigue, and dysarthria. soon after this she became poorly arousable and increasingly somnolent. she had difficulty walking and generalized weakness. on 10/14/94, she lost the ability to walk by herself. evaluation at a local hospital revealed: 1)normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" one of these csf analysis showed: glucose 16, protein 99, wbc 14, rbc 114. echocardiogram was normal. bone marrow biopsy was normal except for decreased iron. abdominal-pelvic ct scan, cxr, mammogram, ppd, ana, tft, and rpr were unremarkable. a 10/31/94 mri brain scan a 5x10mm area of increased signal on t2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. these areas did not enhance with gadolinium contrast on t1 weighted images.,meds: ,none.,pmh:, 1)g3p3, 2)last menses one year ago.,fhx:, mother suffered stroke in her 70's. dm and htn in family.,shx:, married, secretary, no h/o tobacco/etoh/illicit drug use.,ros:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,exam:, bp139/74, hr 90, rr20, 36.8c,ms: drowsy to somnolent, occasionally ""giddy."" oriented to person, place, time. minimal dysarthric speech, but appropriate. mmse 27/30 (copy of exam not in chart).,cn: pupils 4/4 decreasing to 2/2 on exposure to light. optic disks were flat and without sign of papilledema. vfftc. eom intact. no nystagmus. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout. normal muscle tone and bulk.,sensory: no deficit to lt/pp/vib/prop.,coord: difficulty with ram in bue, and ataxia on fnf and hks in all extremities.,station: romberg sign present.,gait: unsteady, wide-based, with notable difficulty on tw, tt and hw.,reflexes: 2/2 bue, 0/1 patellae, trace at both archilles, plantars responses were flexor, bilaterally.,gen exam: unremarkable.,course:, csf analysis by lumbar puncture, 10/31/94: protein 131mg/dl (normal 15-45), albumin 68 (normal 14-20), igg10mg/dl (normal <6.2), igg index -o.1mg/24hr (normal),,no oligoclonal bands seen, wbc 33 (19lymphocytes, 1 neutrophil), rbc 29, glucose 13, cultures (bacteria, fungal, afb) were negative, crytococcal ag negative. the elevated csf total protein, igg, and albumin suggested breakdown of the blood brain barrier or blockage of csf flow. the normal igg synthesis rate and lack of oligoclonal banding did not suggest demylination. a second csf analysis on 11/2/94 revealed similar findings; and in addition anti-purkinje cell and anti-neuronal antibodies (yo and ho) were not found; beta-2 microglobulin was 1.8 (normal); histoplasmosis ag negative. serum ace, spep, urine histoplasmin were negative.,neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the mmpi (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. severe defects in memory, fine motor skills, and constructional praxis were noted.,chest-abdominal-pelvic ct scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the rmca, laca and left aica distributions. it was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of iv steroids. temporal artery biopsy was unremarkable.,she underwent multiple mri brain scans at uihc: 11/4/94, 11/9/94, 11/16/94. all scans consistently showed increase in t2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. these areas did not enhance with gadolinium contrast. these findings were felt most suggestive of glioma.,she underwent left temporal lobe brain biopsy on 11/10/94: this study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. little sign of vasculopathy or tumor was found. bacterial, fungal , hsv, cmv and afb cultures were negative. hsv, and vzv antigen was negative.,her neurological state progressively worsened throughout her hospital stay. by time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required ngt feeding and 24hour supportive care. she was made dnr after family request prior to transfer to a care facility.",21
"preoperative diagnosis: , right renal mass.,postoperative diagnosis: , right renal mass.,procedure: , right radical nephrectomy and assisted laparoscopic approach.,anesthesia:  ,general.,procedure in detail:  ,the patient underwent general anesthesia with endotracheal intubation.  an orogastric was placed and a foley catheter placed.  he was placed in a modified flank position with the hips rotated to 45 degrees.  pillow was used to prevent any pressure points.  he was widely shaved, prepped, and draped.  a marking pen was used to delineate a site for the pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  the incision was made through the premarked site through the skin and subcutaneous tissue.  the aponeurosis of the external oblique was incised in the direction of its fibers.  muscle-splitting incision was made in the internal oblique and transversus abdominis.  the peritoneum was opened and the pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  then, abdominal insufflation was carried out through the pneumo sleeve and the scope was passed through the pneumo sleeve to visualize placement of the trocars in the other two positions.  once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of toldt, so that the colon could be retracted medially.  this exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of gerota fascia was taken down, so that the psoas muscle was exposed.  the attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  the renal artery had been previously noticed on the ct scan to branch early and so each branch was separately ligated and divided using the stapler device.  after the arteries had been divided, the renal vein was divided again using a stapling device.  the remaining attachments superior to the kidney were divided with the harmonic scalpel and also utilized the stapler, and the specimen was removed.  reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with surgicel.  next, the port sites were closed with 0 vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  the estimated blood loss was negligible.  there were no complications.  the patient tolerated the procedure well and left the operating room in satisfactory condition.",20
"xyz, m.d.,re:  abc,dob:  mm/dd/yyyy,dear dr. xyz:,thank you for your kind referral for patient abc.  the patient is being referred for evaluation of diabetic retinopathy.  the patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,on examination, the patient is seeing 20/40 od pinholing to 20/20.  the vision in the left eye is 20/20 uncorrected.  applanation pressures are normal at 17 mmhg bilaterally.  visual fields are full to count fingers ou and there is no relative afferent pupillary defect.  slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis ou.  on dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  the macula, vessels, and periphery are also within normal limits.,in conclusion, mr. abc does not show any evidence of diabetic retinopathy at this time.  we recommended him to have his eyes dilated once a year.  i have advised him to follow up with you for his regular check-ups.  again, thank you for your kind referral of mr. abc and we should check on him once a year at this time.,sincerely,,",25
"identification of patient: , the patient is a 34-year-old caucasian female.,chief complaint:,  depression.,history of present illness:,  the patient's depression began in her teenage years.  sleep has been poor, for multiple reasons.  she has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes.  the patient tends to feel irritable, and has crying spells.  she sometimes has problems with motivation.  she has problems with memory, and energy level is poor. appetite has been poor, but without weight change.  because of her frequent awakening, her cpap machine monitor has indicated she is not using it enough, and medicaid is threatening to refuse to pay for the machine.  she does not have suicidal thoughts.  ,the patient also has what she describes as going into a ""panic mode.""  during these times, she feels as if her whole body is going to explode.  she has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom.  these spells may last a couple of hours, but once lasted for about two day.  she does not get chest pain.  these attacks tend to be precipitated by bills that cannot be paid, or being on a ""time crunch."" ,psychiatric history:,  the patient's nurse practitioner had started her on cymbalta, up to 60 mg per day. this was helpful, but then another physician switched her to wellbutrin in the hope that this would help her quit smoking.  although she was able to cut down on tobacco usage, the depression has been more poorly controlled.  she has used wellbutrin up to 200 mg b.i.d. and cymbalta up to 60 mg per day, at different times.  at age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do.  she has never been hospitalized for psychiatric purposes.  she did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services.  she has not previously spoken with a psychiatrist, but has been seeing a therapist, stephanie kitchen, at this facility.,substance abuse history:,caffeine:  the patient has two or three drinks per day of tea or diet pepsi.,tobacco:  she smokes about one pack of cigarettes per week since being on wellbutrin, and prior to that time had been smoking one-half pack per day.  she is still committed to quitting.,alcohol: denied.,illicit drugs:  denied.  in her earlier years, someone once put some unknown drug in her milk, and she ""came to"" when she was dancing on the table in front of the school nurse.,medical history/review of systems:,constitutional:  see history of present illness. no recent fever or sweats.",31
"preoperative diagnosis: ,incomplete abortion.,postoperative diagnosis: ,incomplete abortion.,procedure performed:, suction dilation and curettage.,anesthesia:  ,general and nonendotracheal by dr. x.,estimated blood loss: , less than 200 cc.,specimens: , endometrial curettings.,drains: , none.,findings:  ,on bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  there was a large amount of tissue obtained on the procedure.,procedure:  ,the patient was taken to the operating room where a general anesthetic was administered.  she was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  next, a weighted speculum was placed in the vagina.  the anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  a size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  two passes were made with the suction curettage.  next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  after the procedure, the vulsellum tenaculum was removed.  the cervix was seemed to be hemostatic.  the weighted speculum was removed.  the patient was given 0.25 mg of methergine im approximately half-way through the procedure.  after the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  it is now approximately eight to ten-week size.  the patient was taken from the operating room in stable condition after she was cleaned.  she will be discharged on today.  she was given methergine, motrin, and doxycycline for her postoperative care.  she will follow-up in one week in the office.",37
"preoperative diagnosis: , morbid obesity. ,postoperative diagnosis: , morbid obesity. ,procedure:,  laparoscopic roux-en-y gastric bypass, antecolic, antegastric with 25-mm eea anastamosis, esophagogastroduodenoscopy. ,anesthesia: , general with endotracheal intubation. ,indications for procedure: , this is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  the patient has now begun to have comorbidities related to the obesity.  the patient has attended our bariatric seminar and met with our dietician and psychologist.  the patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,procedure in detail: , the risks and benefits were explained to the patient.  consent was obtained.  the patient was taken to the operating room and placed supine on the operating room table.  general anesthesia was administered with endotracheal intubation.  a foley catheter was placed for bladder decompression.  all pressure points were carefully padded, and sequential compression devices were placed on the legs.  the abdomen was prepped and draped in standard, sterile, surgical fashion.  marcaine was injected into the umbilicus.",2
"lexiscan myoview stress study,reason for the exam: , chest discomfort.,interpretation: , the patient exercised according to the lexiscan study, received a total of 0.4 mg of lexiscan iv injection.  at peak hyperemic effect, 24.9 mci of myoview were injected for the stress imaging and earlier 8.2 mci were injected for the resting and the usual spect and gated spect protocol was followed and the data was analyzed using cedars-sinai software.  the patient did not walk because of prior history of inability to exercise long enough on treadmill.,the resting heart rate was 57 with the resting blood pressure 143/94.  maximum heart rate achieved was 90 with a maximum blood pressure unchanged.,ekg at rest showed sinus rhythm with no significant st-t wave changes of reversible ischemia or injury.  subtle nonspecific in iii and avf were seen.  maximum stress test ekg showed inverted t wave from v4 to v6.  normal response to lexiscan.,conclusion:  ,maximal lexiscan perfusion with subtle abnormalities non-conclusive.  please refer to the myoview interpretation.,myoview interpretation: , the left ventricle appeared to be normal in size on both stress and rest with no change between the stress and rest with left ventricular end-diastolic volume of 115 and end-systolic of 51.  ef estimated and calculated at 56%.,cardiac perfusion reviewed, showed no reversible defect indicative of myocardium risk and no fixed defect indicative of myocardial scarring.,impression:,1.  normal stress/rest cardiac perfusion with no indication of ischemia.,2.  normal lv function and low likelihood of significant epicardial coronary narrowing.,",3
"bilateral scrotal orchectomy,procedure:,:  the patient is placed in the supine position, prepped and draped in the usual manner.  under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  hemostasis was obtained with the bovie and the spermatic cord was identified.  it was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% marcaine for postoperative pain relief.  the left testicle was delivered through the same incision.  the spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent marcaine.  the incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  a dry sterile dressing fluff and scrotal support applied over that.  the patient was sent to the recovery room in stable condition.",37
"preoperative diagnosis: , symptomatic cholelithiasis.,postoperative diagnosis: , symptomatic cholelithiasis.,procedure: , laparoscopic cholecystectomy and appendectomy (cpt 47563, 44970).,anesthesia: , general endotracheal.,indications:  ,this is an 18-year-old girl with sickle cell anemia who has had symptomatic cholelithiasis.  she requested appendectomy because of the concern of future diagnostic dilemma with pain crisis.  laparoscopic cholecystectomy and appendectomy were recommended to her.  the procedure was explained in detail including the risks of bleeding, infection, biliary injury, retained common duct stones.  after answering her questions, she wished to proceed and gave informed consent.,description of procedure: , the patient was taken to the operating room, placed supine on the operating table.  she was positively identified and the correct surgical site and procedure reviewed.  after successful administration of general endotracheal anesthesia, the skin of the abdomen was prepped with chlorhexidine solution and sterilely draped.,the infraumbilical skin was infiltrated with 0.25% bupivacaine with epinephrine and horizontal incision created.  the linea alba was grasped with a hemostat and veress needle was placed into the peritoneal cavity and used to insufflate carbon dioxide gas to a pressure of 15 mmhg.  a 12-mm expandable disposable trocar was placed and through this a 30 degree laparoscope was used to inspect the peritoneal cavity.  upper abdominal anatomy was normal.  pelvic laparoscopy revealed bilaterally closed internal inguinal rings.  additional trocars were placed under direct vision including a 5-mm reusable in the right lateral _____.  there was a 12-mm expandable disposable in the right upper quadrant and a 5-mm reusable in the subxiphoid region.  using these, the gallbladder was grasped and retraced cephalad.  adhesions were taken down over the cystic duct and the duct was circumferentially dissected and clipped at the gallbladder cystic duct junction.  a small ductotomy was created.  reddick cholangiogram catheter was then placed within the duct and the balloon inflated.  continuous fluoroscopy was used to instill contrast material.  this showed normal common bile duct which entered the duodenum without obstruction.  there was no evidence of common bile duct stones.  the cholangiogram catheter was removed.  the duct was doubly clipped and divided.  the artery was divided and cauterized.  the gallbladder was taken out of the gallbladder fossa.  it was then placed in endocatch bag and left in the abdomen.  attention was then paid to the appendix.  the appendix was identified and window was made in the mesoappendix at the base.  this was amputated with an endo-gia stapler.  the mesoappendix was divided with an endo-gia vascular stapler.  this was placed in another endocatch bag.  the abdomen was then irrigated.  hemostasis was satisfactory.  both the appendix and gallbladder were removed and sent for pathology.  all trocars were removed.  the 12-mm port sites were closed with 2-0 pds figure-of-eight fascial sutures.  the umbilical skin was reapproximated with interrupted 5-0 vicryl rapide.  the remaining skin incisions were closed with 5-0 monocryl subcuticular suture.  the skin was cleaned.  mastisol, steri-strips and band-aids were applied.  the patient was awakened, extubated in the operating room, transferred to the recovery room in stable condition.",14
"reason for exam: , vegetation and bacteremia.,procedure: , transesophageal echocardiogram.,interpretation: , the procedure and its complications were explained to the patient in detail and formal consent was obtained.  the patient was brought to special procedure unit.  his throat was anesthetized with lidocaine spray.  subsequently, 2 mg of iv versed was given for sedation.  the patient was positioned.  probe was introduced without any difficulty.  the patient tolerated the procedure very well.  probe was taken out.  no complications were noted.  findings are as mentioned below.,findings:,1.  left ventricle has normal size and dimensions with normal function.  ejection fraction of 60%.,2.  left atrium and right-sided chambers were of normal size and dimensions.,3.  left atrial appendage is clean without any clot or smoke effect.,4.  atrial septum is intact.  bubble study was negative.,5.  mitral valve is structurally normal.,6.  aortic valve reveals echodensity suggestive of vegetation.,7.  tricuspid valve was structurally normal.,8.  doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  aorta is benign.,impression:,1.  normal left ventricular size and function.,2.  echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  doppler study as above most pronounced being moderate-to-severe aortic insufficiency.",3
"subjective:,  his brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  the patient started improving his diet when he received the letter explaining his lipids are elevated.  he is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  he has started packing his lunch three to four times per week instead of eating out so much.  he is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  he is in training for a triathlon.  he says he is already losing weight due to his efforts.,objective:,  height:  6 foot 2 inches.  weight:  204 pounds on 03/07/05.  ideal body weight:  190 pounds, plus or minus ten percent.  he is 107 percent standard of midpoint ideal body weight.  bmi:  26.189.  a 48-year-old male.  lab on 03/15/05:  cholesterol:  251.  ldl:  166.  vldl:  17.  hdl:  68.  triglycerides:  87.  i explained to the patient the dietary guidelines to help improve his lipids.  i recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  i went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  i encouraged him to continue as he is doing.,assessment:,  basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  his 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  he needs to continue as he is doing.  he verbalized understanding and seemed receptive.,plan:,  the patient plans to recheck his lipids through dr. xyz  i gave him my phone number and he is to call me if he has any further questions regarding his diet.",9
"admitting diagnoses,1. prematurity.,2. appropriate for gestational age.,3. maternal group b streptococcus positive culture.,discharge diagnoses,1. prematurity, 34 weeks' gestation, now 5 days old.,2. group b streptococcus exposure, but no sepsis.,3. physiologic jaundice.,4. feeding problem.,history of illness:  ,this is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an edc of november 19, 2003.  group b streptococcus culture was positive on september 29, 2003, and betamethasone was given 1 dose prior to delivery.  mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  the infant delivered vaginally, had a double nuchal cord and required cpap and free flow oxygen.  her apgars were 8 at 1 minute and 9 at 5 minutes.  at the end of delivery, it was noted there was a partial placental abruptio.,hospital course:  ,the infant has had a basically uncomplicated hospital course.  she did not require oxygen.  she did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group b streptococcus.  the culture was negative and the antibiotics were stopped at 48 hours.,the infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  she was treated for approximately 24 hours with phototherapy and the bilirubin on october 15, 2003 was 3.4.,feeding: , the infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 ml every feeding and is taking formula or breast milk, that is, ___ 24 calories per ounce.,physical examination:, ,vital signs:  at discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,heent:  head is normocephalic.  eyes are without conjunctival injection.  red reflex is elicited bilaterally.  tms not well visualized.  nose and throat are patent without palatal defect.,neck:  supple without clavicular fracture.,lungs:  clear to auscultation.,heart:  regular rate without murmur, click or gallop present.,extremities:  pulses are 2/4 for brachial and femoral.  extremities without evidence of hip defects.,abdomen:  soft, bowel sounds present.  no masses or organomegaly.,genitalia:  normal female, but the clitoris is not covered by the labia majora.,neurological:  the infant has good moro, grasp, and suck reflexes.,instructions for continuing care,the infant will be discharged home.  she will have home health visits one time per week for 3 weeks, and she will be seen in followup at san juan pediatrics the week of october 20, 2003.  she is to continue feeding with either breast milk or formula, that is, ___ to 24 calories per ounce.,condition: , her condition at discharge is good.",10
"cc:, memory loss.,hx:, this 77 y/o rhf presented with a one year history of progressive memory loss. two weeks prior to her evaluation at uihc she agreed to have her sister pick her up for church at 8:15am, sunday morning. that sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. she later called the sister and asked her if she (sister) had overslept. during her uihc evaluation she denied she knew anything about the incident. no other complaints were brought forth by the patients family.,pmh:, unremarkable.,meds:, none,fhx: ,father died of an mi, mother had dm type ii.,shx: , denies etoh/illicit drug/tobacco use.,ros:, unremarkable.,exam:, afebrile, 80bpm, bp 158/98, 16rpm. alert and oriented to person, place, time. euthymic. 29/30 on folstein's mmse with deficit on drawing. recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. digit span was five forward and three backward. cn: mild right lower facial droop only. motor: full strength throughout. sensory: no deficits to pp/vib/prop/lt/temp. coord: poor ram in lue only. gait: nb and ambulated without difficulty. station: no drift or romberg sign. reflexes: 3+ bilaterally with flexor plantar responses. there were no frontal release signs.,labs:, cmb, general screen, ft4, tsh, vdrl were all wnl.,neuropsychological evaluation, 12/7/92: ,verbal associative fluency was defective. verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. visual memory, including immediate and delayed recall was also severely impaired. visuoperceptual discrimination was mildly impaired, as was 2-d constructional praxis.,hct, 12/7/92: , diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. calcification is seen in both globus pallidi and this was felt to be a normal variant.",21
"reason for visit:,  this 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia.,history of present illness: , the patient presented initially to the pulmonary clinic with dyspnea on minimal exertion.  at that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue.  she also complained of nocturnal choking episodes that have since abated over the past several months.  in the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results.,the patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m.  she reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night.  she reports tossing and turning throughout the night and awakening with the sheets in disarray.  she reports that her sleep was much better quality in the sleep laboratory as compared to home.  when she awakens, she might have a dull headache and feels tired in the morning.  her daughter reports that she has heard the patient talking during sleep and snoring.  there are no apneic episodes.  the patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks.,during the daytime, the patient reports spending a lot of sedentary time reading and watching tv.  she routinely dozes off during these sedentary activities.  she also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours.,the patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner.,she reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago.  since that time, her weight is down by approximately 30 pounds.,the patient is managed in outpatient psychiatry and at her maintenance clinic.  she takes methadone, trazodone, and seroquel.,past medical history:,1.  depression.,2.  hepatitis c.,3.  hypertension.,4.  inhaled and intravenous drug abuse history.,the patient has a history of smoking two packs per day of cigarettes for approximately 25 pounds.  she also has a history of recurrent atypical chest pain for which she has been evaluated.,family history: , as previously documented.,social history:  ,the patient has a history of inhalation on intravenous drug abuse.  she is currently on methadone maintenance.  she is being followed in psychiatry for depression and substance abuse issues.  she lives with a room-mate.,review of systems:,  not contributory.,medications: , current medications include the following:,1.  methadone 110 mg by mouth every day.,2.  paxil 60 mg by mouth every day.,3.  trazodone 30 mg by mouth nightly.,4.  seroquel 20 mg by mouth nightly.,5.  avalide (irbesartan) and hydrochlorothiazide.,6.  albuterol and flovent inhalers two puffs by mouth twice a day.,7.  atrovent as needed.,findings: , vital signs:  blood pressure 126/84, pulse 67, respiratory rate 18, weight 232 pounds, height 5 feet 8 inches, temperature 97.4 degrees, sao2 is 99 percent on room air at rest.  heent:  sclerae anicteric.  conjunctivae pink.  extraocular movements are intact.  pupils are equal, round, and reactive to light.  the nasal passages show deviation in the nasal septum to the right.  there is a slight bloody exudate at the right naris.  some nasal mucosal edema was noted with serous exudate bilaterally.  the jaw is not foreshortened.  the tongue is not large.  mallampati airway score was 3.  the oropharynx was not shallow.  there is no pharyngeal mucosa hypertrophy.  no tonsillar tissue noted.  the tongue is not large.  neck is supple.  thyroid without nodules or masses.  carotid upstrokes normal.  no bruits.  no jugular venous distention.  chest is clear to auscultation and percussion.  no wheezing, rales, rhonchi or adventitious sounds.  no prolongation of the expiratory phase.  cardiac:  pmi not palpable.  regular rate and rhythm.  s1 and s2 normal.  no murmurs or gallops.  abdomen:  nontender.  bowel sounds normal.  no liver or spleen palpable.  extremities:  no clubbing or cyanosis.  there is 1+ pretibial edema.  pulses are 2+ in upper and lower extremities.  neurologic:  grossly nonfocal.,laboratories:,  pulmonary function studies reportedly show a mild restrictive ventilatory defect without obstruction.  diffusing capacity is well preserved.,an overnight sleep study was performed on this patient at the end of 02/07.  at that time, she reported that her sleep was better in the laboratories compared to home.  she slept for a total sleep time of 398 minutes out of 432 minutes in bed (sleep proficiency 92 percent).  she fell asleep in the middle of latency of less than 1 minute.  she woke up after sleep onset of 34 minutes.  she had stage i sleep that was some elevated at 28 percent of total sleep time, and stage i sleep is predominantly evident in the lateral portion of the night.  the remainders were stage ii at 69 percent, stage iii and iv at 3 percent of total sleep time.,the patient had no rem sleep.,the patient had no periodic limb movements during sleep.,the patient had no significant sleep-disordered breathing during non-rem sleep with less than one episode per hour.  oxyhemoglobin saturation remained in the low to mid 90s throughout the night.,intermittent inspiratory flow limitation compatible with snoring was observed during non-rem sleep.,assessment and plan: , this patient presents with history of sleep disruption and daytime sleepiness with fatigue.  her symptoms are multifactorial.,regarding the etiology of difficulty in initiating and maintaining sleep, the patient has a component of psychophysiologic insomnia, based on reports of better sleep in the laboratory as compared to home.  in addition, nontrivial smoking in the home setting may be contributing significantly to sleep disruption.,regarding her daytime sleepiness, the patient is taking a number of long-acting central nervous system acting medications to sedate her and can produce a lasting sedation throughout the daytime.  these include trazodone, seroquel, and methadone.  of these medications, the methadone is clearly indicative, given the history of substance abuse.  it would be desirable to reduce or discontinue trazodone and then perhaps consider doing the same with seroquel.  i brought this possibility up with the patient, and i asked her to discuss this further with her psychiatrist.,finally, to help mitigate sleep disruption at night, i have provided her with tips for sleep hygiene.  these include bedtime rituals, stimulus control therapy, and sleep restriction as well as avoidance of nicotine in the evening hours.",34
"preoperative diagnosis (es):,1. endocarditis.,2. status post aortic valve replacement with st. jude mechanical valve.,3. pericardial tamponade.,postoperative diagnosis (es):,1. endocarditis.,2. status post aortic valve replacement with st. jude mechanical valve.,3. pericardial tamponade.,procedure:,1. emergent subxiphoid pericardial window.,2. transesophageal echocardiogram.,anesthesia:, general endotracheal.,findings:, the patient was noted to have 600 ml of dark bloody fluid around the pericardium. we could see the effusion resolve on echocardiogram. the aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. there was no evidence of endocarditis. the mitral valve leaflets moved normally with some mild mitral insufficiency.,description of the operation:, the patient was brought to the operating room emergently. after adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. a small incision was made at the bottom of the previous sternotomy incision. the subcutaneous sutures were removed. the dissection was carried down into the pericardial space. blood was evacuated without any difficulty. pericardial blake drain was then placed. the fascia was then reclosed with interrupted vicryl sutures. the subcutaneous tissues were closed with a running monocryl suture. a subdermal pds followed by a subcuticular monocryl suture were all performed. the wound was closed with dermabond dressing. the procedure was terminated at this point. the patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.",37
"cc:, confusion and slurred speech.,hx , (primarily obtained from boyfriend): this 31 y/o rhf experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. she apparently recovered within 24 hours. for two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). she left a stove on.,she began slurring her speech 2 days prior to admission. on the day of presentation she developed right facial weakness and began stumbling to the right. she denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. there was no history of illicit drug/etoh use or head trauma.,pmh:, migraine headache.,fhx: , unremarkable.,shx: ,divorced. lives with boyfriend. 3 children alive and well. denied tobacco/illicit drug use. rarely consumes etoh.,ros:, irregular menses.,exam: ,bp118/66.  hr83. rr 20. t36.8c.,ms: alert and oriented to name only. perseverative thought processes. utilized only one or two word answers/phrases. non-fluent. rarely followed commands. impaired writing of name.,cn: flattened right nasolabial fold only.,motor: mild weakness in rue manifested by pronator drift. other extremities were full strength.,sensory: withdrew to noxious stimulation in all 4 extremities.,coordination: difficult to assess.,station: right pronator drift.,gait: unremarkable.,reflexes: 2/2bue, 3/3ble, plantars were flexor bilaterally.,general exam: unremarkable.,initial studies:, cbc, gs, ua, pt, ptt, esr, crp, ekg were all unremarkable. outside hct showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,course: ,mri brian scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left mca distribution suggesting slow flow. the latter suggested a vasculopathy such as moya moya, or fibromuscular dysplasia. hiv, ana, anti-cardiolipin antibody titer, cardiac enzymes, tfts, b12, and cholesterol studies were unremarkable.,she underwent a cerebral angiogram on 2/12/92. this revealed an occlusion of the left mca just distal to its origin. the distal distribution of the left mca filled on later films through collaterals from the left aca. there was also an occlusion of the right mca just distal to the temporal branch. distal branches of the right mca filled through collaterals from the right aca. no other vascular abnormalities were noted. these findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as moya moya disease. she was subsequently given this diagnosis. neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. she had long latencies responding and understood only simple questions. affect was blunted and there was distinct lack of concern regarding her condition. she was subsequently discharged home on no medications.,in 9/92 she was admitted for sudden onset right hemiparesis and mental status change. exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. ob/gyn exam including cervical biopsy, and abdominal/pelvic ct scanning revealed stage iv squamous cell cancer of the cervix. she died 9/24/92 of cervical cancer.",21
"preoperative diagnosis:,  complex regional pain syndrome type i.,postoperative diagnosis: , same.,procedure:,1.  stellate ganglion rftc (radiofrequency thermocoagulation)  left side.,2.  interpretation of radiograph.,anesthesia:  ,iv sedation with versed and fentanyl.,estimated blood loss:,  none.,complications:,  none.,indications: , patient with reflex sympathetic dystrophy, left side.  positive for allodynia, pain, mottled appearance, skin changes upper extremities as well as swelling.,summary of procedure: , patient is admitted to the operating room.  monitors placed, including ekg, pulse oximeter, and bp cuff.  patient had a pillow placed under the shoulder blades.  the head and neck was allowed to fall back into hyperextension.  the neck region was prepped and draped in sterile fashion with betadine and alcohol.  four sterile towels were placed.  the cricothyroid membrane was palpated, then going one finger's breadth lateral from the cricothyroid membrane and one finger's breadth inferior, the carotid pulse was palpated and the sheath was retracted laterally.  a 22 gauge smk 5-mm bare tipped needle was then introduced in between the cricothyroid membrane and the carotid sheath and directed inferiomedially.  the needle is advanced prudently through the tissues, avoiding the carotid artery laterally.  the tip of the needle is perceived to intersect with the vertebral body of cervical #7 and this was visualized by fluoroscopy.  aspiration was cautiously performed after the needle was retracted approximately 1 mm and held steady with left hand.  no venous or arterial blood return is noted.  no cerebral spinal fluid is noted.  positive sensory stimulation was elicited using the radionics unit at 50 hz from 0-0.1 volts and negative motor stimulation was elicited from 1-10 volts at 2 hz.  after negative aspiration through the 22 gauge smk 5mm bare tipped needle is absolutely confirmed, 5 cc of solution (solution consisting of 5 cc of 0.5% marcaine, 1 cc of triamcinolone) was then injected into the stellate ganglion region.  this was done with intermittent aspiration vigilantly verifying negative aspiration.  the stylet was then promptly replaced and neurolysis (nerve decompression) was then carried out for 60 seconds at 80 degrees centigrade.  this exact same procedure using the exact same protocol was repeated one more time to complete the two lesions of the stellate ganglion.  the patient was immediately placed in the sitting position to reduce any side effect from the stellate ganglion block associated with cephalad spread of the solution.  pressure was placed over the puncture site for approximately five minutes to eliminate any hemorrhage from blood vessels that may have been punctured and a band-aid was placed over the puncture site.  patient was monitored for an additional ten to fifteen minutes and was noted to have tolerated the procedure well without any adverse sequelae.  significant temperature elevation was noted on the affected side verifying neurolysis of the ganglion.  ,interpretation of radiograph reveals placement of the 22-gauge smk 5-mm bare tipped needle in the region of the stellate ganglion on the affected side.  four lesions were carried out.",32
"exam:,mri left shoulder,clinical:,this is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. received for second opinion. study performed on 10/04/05.,findings:,the patient was scanned in a 1.5 tesla magnet.,there is a flat undersurface of the acromion (type i) morphology, with anterior downsloping orientation.,there is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo t2 series #3 images #6-9). there is edema with thickening of the superior glenohumeral ligament (axial t2 series #3 image #7). there is flattening of the long biceps tendon as it enters the bicipital groove (axial t2 series #3 image #9-10), but no subluxation. the findings suggest early changes of a “hidden” lesion.,normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,there is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial t2 series #3 image #10). there is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,normal anterior and posterior glenoid labra.,normal supraspinatus, infraspinatus, and teres minor tendons.,normal muscles of the rotator cuff and there is no muscular atrophy.,there is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal t2 series #7 image #5; coronal t2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,normal acromioclavicular articulation.,impression:,inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. findings suggest early changes of a hidden lesion.,mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,type i morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.",32
"indication: ,  rectal bleeding, constipation, abnormal ct scan, rule out inflammatory bowel disease.,premedication: ,see procedure nurse ncs form.,procedure:  ,",14
"preoperative diagnoses,1.  post anterior cervical discectomy and fusion at c4-c5 and c5-c6 with possible pseudoarthrosis at c4-c5.,2.  cervical radiculopathy involving the left arm.,3.  disc degeneration at c3-c4 and c6-c7.,postoperative diagnoses,1.  post anterior cervical discectomy and fusion at c4-c5 and c5-c6 with possible pseudoarthrosis at c4-c5.,2.  cervical radiculopathy involving the left arm.,3.  disc degeneration at c3-c4 and c6-c7.,operative procedures,1.  decompressive left lumbar laminectomy c4-c5 and c5-c6 with neural foraminotomy.,2.  posterior cervical fusion c4-c5.,3.  songer wire.,4.  right iliac bone graft.,technique:  ,the patient was brought to the operating room.  preoperative evaluations included previous cervical spine surgery.  the patient initially had some relief; however, his left arm pain did recur and gradually got worse.  repeat studies including myelogram and postspinal cts revealed some blunting of the nerve root at c4-c5 and c5-c6.  there was also noted to be some annular bulges at c3-c4, and c6-c7.  the ct scan in march revealed that the fusion was not fully solid.  x-rays were done in november including flexion and extension views, it appeared that the fusion was solid.,the patient had been on pain medication.  the patient had undergone several nonoperative treatments.  he was given the option of surgical intervention.  we discussed botox, i discussed with the patient and posterior cervical decompression.  i explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  if at the time of surgery there was some motion of the c4-c5 level, i would recommend a fusion.  the patient was a smoker and had been advised to quit smoking but has not quit smoking.  i have therefore recommended that he use iliac bone graft.  i explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,the patient also was advised that if i did a fusion, i would also use post instrumentation, which was a wire.  the wire would be left permanently.,even with all these procedures, there was no guarantee that his symptoms would improve.  his numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  he still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  other procedures may be necessary later.  there is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  he could lose total control of his arms or legs and end up in the bed for the rest of his life.  he could develop chronic regional pain syndromes.  he could get difficulty swallowing or eating.  he could have substantial weakness in the arm.  he was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,he was also offered his records if he would like any other pain medications or seek other treatments, he was advised that dr. x would continue to prescribe pain medication if he did not wish to proceed with surgery.,he stated he understood all the risks.  he did not wish to get any other treatments.  he said the pain has reached the point that he wished to proceed with surgery.,procedure in detail: , in the operating room, he was given general endotracheal anesthesia.,i then carefully rolled the patient on thoracic rolls.  his head was controlled by a horseshoe holder.  the anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  the arms, the right hip, and the neck was then prepped and draped.  care was taken to position both arms and both legs.  pulses were checked.,a midline incision was made through the skin and subcutaneous tissue on the cervical spine.  a loupe magnification and headlamp illumination was used.  bleeding vessels were cauterized.  meticulous hemostasis was carried out throughout the procedure.  gradually and carefully i exposed the spinous process of the c6, c5, and c4.  a lateral view was done after an instrument in place.  this revealed the c6-c7 level.  i therefore did a small laminotomy opening at c4-c5.  i placed an instrument and x-rays confirmed c4-c5 level.,i stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,once i identified the level, i then used a bur to thin the lamina of c5.  i used a 1-mm, followed by a 2-mm kerrison rongeur to carefully remove the lamina off c5 on the left.  i removed some of the superior lamina of c6 and some of the inferior lamina of c4.  this allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the c5 and c6 nerve roots.  there was some bleeding from the epidural veins and a bipolar cautery was used.  absolutely no retractors were ever placed in the canal.  there was no retraction.  i was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,at the end of the procedure, the neuroforamen were widely patent.  the nerve roots had been fully decompressed.,i then checked stability.  there was micromotion at the c4-c5 level.  i therefore elected to proceed with a fusion.,i debrided the interspinous ligament between c4 and c5.  i used a bur to roughen up the surface of the superior portion of the spinous process of c5 and the inferior portion of c4.  using a small drill, i opened the facet at c4-c5.  i then used a very small curette to clean up the articular cartilage.  i used a bur then to roughen up the lamina at c4-c5.,attention was turned to the right and left hip, which was also prepped.  an incision made over the iliac crest.  bleeding vessels were cauterized.  i exposed just the posterior aspect of the crest.  i removed some of the bone and then used the curette to remove cancellous bone.,i placed the songer wire through the base of the spinous process of c4 and c5.  drill holes made with a clip.  i then packed cancellous bone between the decorticated spinous process.  i then tightened the songer wire to the appropriate tension and then cut off the excess wire.,prior to tightening the wire, i also packed cancellous bone with facet at c4-c5.  i then laid bone upon the decorticated lamina of c4 and c5.,the hip wound was irrigated with bacitracin and kantrex.  deep structures were closed with #1 vicryl, subcutaneous suture and subcuticular tissue was closed.,no drain was placed in the hip.,a drain was left in the posterior cervical spine.  the deep tissues were closed with 0 vicryl, subcutaneous tissue and skin were then closed.  the patient was taken to the recovery room in good condition.",26
"history:,  i had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  as you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  she states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  she had a ct of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when i reviewed the films and there is some minimal nasal septum deviation to the left.  she currently is not taking any medication for her sinuses.  she also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  she has tried topical nasal corticosteroid therapy without much improvement.  she tried allegra without much improvement and she believes the allegra may have caused problems with balance to worsen.  she notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  she denies any previous history of sinus surgery or nasal injury.  she believes she has some degree of allergy symptoms.,past medical history:  ,seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  she is currently 180 pounds.,past surgical history:,  lower extremity vein stripping, tonsillectomy and adenoidectomy.,family history: , strong for heart disease and alcoholism.,current medications: , dynacirc.,allergies: , egg-based products cause hives.,social history:  ,the patient used to smoke cigarettes for about 20 years, one-half pack a day.  she currently does not, which was encouraged to continue.  she rarely drinks any alcohol-containing beverages.,physical examination: ,vital signs:  age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,general:  the patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,head:  normocephalic.  no masses or lesions noted.,face:  no facial tenderness or asymmetry noted.,eyes:  pupils are equal, round and reactive to light and accommodation bilaterally.  extraocular movements are intact bilaterally.  no nystagmus.,ears:  during hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  no nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  no evidence of any orthostatic hypotension was noted during the exam.  tympanic membranes were noted to be intact.  no signs of middle ear effusion or ear canal inflammation.,nose:  the patient appears congested.  turbinate hypertrophy is noted.  there are no signs of any acute sinusitis.  septum is midline, slightly deviated to the left.,throat:  there is clear postnasal drip.  oral hygiene is good.  no masses or lesions noted.  both vocal cords move well to midline.,neck:  the neck is supple with no adenopathy or masses palpated.  the trachea is midline.  the thyroid gland is of normal size with no nodules.,lungs:  clear to auscultation bilaterally.  no wheeze noted.,heart:  regular rate and rhythm.  no murmur noted.,neurologic:  facial nerve is intact bilaterally.  the remaining cranial nerves are intact without focal deficit.,procedure: , fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,impression:  ,1.  probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  inferior turbinate hypertrophy.,4.  nasal septum deformity.,recommendations:,  an eng was ordered to evaluate vestibular function.  she was placed on veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  a medrol dosepak was prescribed as directed.  the patient was given instruction on use of nasal saline irrigation to be used twice daily and clarinex 5 mg daily was recommended.  after the patients' eng examination, we will see the patient back for further evaluation and treatment recommendations.  in light of the patient's atypical dizziness symptoms, i cannot rule out other pathology at this time, and i informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,thank you for allowing me to participate with the care of your patient.",5
"history of present illness:,  a 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  this has been problematic over the last several months and is just worsening to the point where it is impairing her work.  her boss asks her if she was actually on drugs in which she said no.  she stated may be she needed to be, meaning taking some medications.  the patient had been prescribed wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  she has not been on any other antidepressants in the past.  she is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  she denies any hot flashes or night sweats.  she underwent tah with bso in december of 2003.,family history: , benign breast lump in her mother; however, her paternal grandmother had breast cancer.  the patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  she was recently treated for sinusitis.,allergies:,  she is allergic to sulfa.,current medications:,  recently finished minocin and duraphen ii dm.,physical examination:,general:  a well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  mood is dysthymic.  affect is tearful.,skin:  without rash.,eyes:  perrla.  conjunctivae are clear.,neck:  supple with adenopathy or thyromegaly.,lungs:  clear.,heart:  regular rate and rhythm without murmur.,assessment:,1.  postsurgical menopause.,2.  mood swings.,plan:,  i spent about 30 minutes with the patient discussing treatment options.  i do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  we will try starting her back on wellbutrin xl 150 mg daily.  she may increase to 300 mg daily after three to seven days.  samples provided initially.  if she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  i also recommended increasing her exercise.  we will also obtain some screening lab work including cbc, ua, tsh, chemistry panel, and lipid profile.  follow up here in two weeks or sooner if any other problems.  she is needing her annual breast exam as well.",5
"male physical examination,eye:  eyelids normal color, no edema.  conjunctivae with no erythema, foreign body, or lacerations.  sclerae normal white color, no jaundice.  cornea clear without lesions.  pupils equally responsive to light.  iris normal color, no lesions.  anterior chamber clear.  lacrimal ducts normal.  fundi clear.,ear:  external ear has no erythema, edema, or lesions.  ear canal unobstructed without edema, discharge, or lesions.  tympanic membranes clear with normal light reflex.  no middle ear effusions.,nose:  external nose symmetrical.  no skin lesions.  nares open and free of lesions.  turbinates normal color, size and shape.  mucus clear.  no internal lesions.,throat:  no erythema or exudates.  buccal mucosa clear.  lips normal color without lesions.  tongue normal shape and color without lesion.  hard and soft palate normal color without lesions.  teeth show no remarkable features.  no adenopathy.  tonsils normal shape and size.  uvula normal shape and color.,neck:  skin has no lesions.  neck symmetrical.  no adenopathy, thyromegaly, or masses.  normal range of motion, nontender.  trachea midline.,chest:  symmetrical.  clear to auscultation bilaterally.  no wheezing, rales or rhonchi.  chest nontender.  normal lung excursion.  no accessory muscle use.,cardiovascular:  heart has regular rate and rhythm with no s3 or s4.  heart rate is normal.,abdominal:  soft, nontender, nondistended, bowel sounds present.  no hepatomegaly, splenomegaly, masses, or bruits.,genital:  penis normal shape without lesions.  testicles normal shape and contour without tenderness.  epididymides normal shape and contour without tenderness.  rectum normal tone to sphincter.  prostate normal shape and contour without nodules.  stool hemoccult negative.  no external hemorrhoids.  no skin lesions.,musculoskeletal:  normal strength all muscle groups.  normal range of motion all joints.  no joint effusions.  joints normal shape and contour.  no muscle masses.,foot:  no erythema.  no edema.  normal range of motion all joints in the foot.  nontender.  no pain with inversion, eversion, plantar or dorsiflexion.,ankle:  anterior and posterior drawer test negative.  no pain with inversion, eversion, dorsiflexion, or plantar flexion.  collateral ligaments intact.  no joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,knee:  normal range of motion.  no joint effusion, erythema, nontender.  anterior and posterior drawer tests negative.  lachman's test negative.  collateral ligaments intact.  bursas nontender without edema.,wrist:  normal range of motion.  no edema or effusion, nontender.  negative tinel and phalen tests.  normal strength all muscle groups.,elbow:  normal range of motion.  no joint effusion or erythema.  normal strength all muscle groups.  nontender.  olecranon bursa flat and nontender, no edema.  normal supination and pronation of forearm.  no crepitus.,hip:  negative swinging test.  trochanteric bursa nontender.  normal range of motion.  normal strength all muscle groups.  no pain with eversion and inversion.  no crepitus.  normal gait.,psychiatric:  alert and oriented times four.  no delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  affect is appropriate.  no psychomotor slowing or agitation.  eye contact is appropriate.",15
"physical examination,general appearance: , well developed, well nourished, in no acute distress.,vital signs:,  ***,skin:  ,inspection of the skin reveals no rashes, ulcerations or petechiae.,heent:,  the sclerae were anicteric and conjunctivae were pink and moist.  extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  external inspection of the ears and nose showed no scars, lesions, or masses.  lips, teeth, and gums showed normal mucosa.  the oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,neck:  ,supple and symmetric.  there was no thyroid enlargement, and no tenderness, or masses were felt.,chest: , normal ap diameter and normal contour without any kyphoscoliosis.,lungs: , auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,cardiovascular:  ,there was a regular rate and rhythm without any murmurs, gallops, rubs.  the carotid pulses were normal and 2+ bilaterally without bruits.  peripheral pulses were 2+ and symmetric.,abdomen:  ,soft and nontender with normal bowel sounds.  the liver span was approximately 5-6 cm in the right midclavicular line by percussion.  the liver edge was nontender.  the spleen was not palpable.  there were no inguinal or umbilical hernias noted.  no ascites was noted.,rectal:  ,normal perineal exam.  sphincter tone was normal.  there was no external hemorrhoids or rectal masses.  stool hemoccult was negative.  the prostate was normal size without any nodules appreciated (men only).,lymph nodes: , no lymphadenopathy was appreciated in the neck, axillae or groin.,musculoskeletal: , gait was normal.  there was no tenderness or effusions noted.  muscle strength and tone were normal.,extremities: , no cyanosis, clubbing or edema.,neurologic:  ,alert and oriented x 3.  normal affect.  gait was normal.  normal deep tendon reflexes with no pathological reflexes.  sensation to touch was normal.",5
"history of present illness:, the patient is a 71-year-old caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on cpap, diabetic foot ulcer, anemia and left lower extremity cellulitis. she was brought in by the ems service to erlanger emergency department with pulseless electrical activity. her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. she became acutely unresponsive. she was noted to have worsening of her breathing. she took several of her mdis and then was placed on her cpap. he went to notify ems and when he returned, she was found to not be breathing. he stated that she was noted to have no breathing in excess of 10 minutes. he states that the ems system arrived at the home and she was found not breathing. the patient was intubated at the scene and upon arrival to erlanger medical center, she was found to have pupils fixed and dilated. she was seen by me in the emergency department and was on neo-synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state.,review of systems:, review of systems was not obtainable.,past medical history:, diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia.,past surgical history:, noncontributory to above.,family history:, mother with history of coronary artery disease.,social history:, the patient is married. she uses no ethanol, no tobacco and no illicits. she has a very support family unit.,medications:, augmentin; detrol la; lisinopril.,immunizations:, immunizations were up to date for influenza, negative for pneumovax.,allergies:, penicillin.,laboratory at presentation:, white blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. sodium 148, potassium 5.2, bun 30, creatinine 2.2 and glucose 216. pt was 22.4.,radiologic data:, chest x-ray revealed a diffuse pulmonary edema.,physical examination:,vital signs: blood pressure 97/52, pulse of 79, respirations 16, o2 sat 100%.,heent: the patient's pupils were again, fixed and dilated and intubated on the monitor.,chest: poor air movement bilateral with bilateral rales.,cardiovascular: regular rate and rhythm.,abdomen: the abdomen was obese, nondistended and nontender.,extremities: left diabetic foot had oozing pus drainage from the foot.,gu: foley catheter was in place.,impression and plan:,1. acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: will continue ventilator support. will rule out pulmonary embolus, rule out myocardial infarction. continue pressors. the patient is currently on dopamine, neo-synephrine and levophed.,2. acute respiratory distress syndrome: will continue ventilatory support.,3. questionable sepsis: will obtain blood cultures, intravenous vancomycin and rocephin given.,4. hypotensive shock: will continue pressors. will check random cortisol. hydrocortisone was added.,further inpatient management for this patient will be provided by dr. r. the patient's status was discussed with her daughter and her husband. the husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. he states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. the family will make an assessment and final decision concerning her long-term management after a 24 hour period.",15
"subjective:,  mom brings patient in today because of sore throat starting last night.  eyes have been very puffy.  he has taken some benadryl when all of this congestion started but with a sudden onset just yesterday.  he has had low-grade fever and just felt very run down, appearing very tired.  he is still eating and drinking well, and his voice has been hoarse but no coughing.  no shortness of breath, vomiting, diarrhea or abdominal pain.,past medical history:,  unremarkable.  there is no history of allergies.  he does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,family history: , noncontributory.  no one else at home is sick.,objective:,general:  a 13-year-old male appearing tired but in no acute distress.,neck:  supple without adenopathy.,heent:  ear canals clear.  tms, bilaterally, gray in color.  good light reflex.  oropharynx pink and moist.  no erythema or exudate.  some drainage is seen in the posterior pharynx.  nares:  swollen, red.  no drainage seen.  no sinus tenderness.  eyes are clear.,chest:  respirations are regular and nonlabored.,lungs:  clear to auscultation throughout.,heart:  regular rhythm without murmur.,skin:  warm, dry and pink, moist mucous membranes.  no rash.,laboratory:,  strep test is negative.  strep culture is negative.,radiology:,  water's view of the sinuses is negative for any sinusitis or acute infection.,assessment:,  upper respiratory infection.,plan:,  at this point just treat symptomatically.  i gave him some samples of levall for the congestion and as an expectorant.  push fluids and rest.  may use ibuprofen or tylenol for discomfort.",15
"preoperative diagnosis: , nonpalpable neoplasm, right breast.,postoperative diagnosis: , deferred for pathology.,procedure performed:  ,needle localized wide excision of nonpalpable neoplasm, right breast.,specimen: , mammography.,gross findings:  ,this 53-year-old caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  after excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  this too was excised.,operative procedure:  ,the patient was taken to the operating room, placed in supine position in the operating table.  intravenous sedation was administered by the anesthesia department.  the kopans wire was trimmed to an appropriate length.  the patient was sterilely prepped and draped in the usual manner.  local anesthetic consisting of 1% lidocaine and 0.5% marcaine was injected into the proposed line of incision.  a curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  the wire was stabilized and brought to protrude through the incision.  skin flaps were then generated with electrocautery.  a generous core tissue was grasped with allis forceps and excised with electrocautery.  prior to complete excision, the superior margin was marked with a #2-0 vicryl suture, which was tied and cut short.  the lateral margin was marked with a #2-0 vicryl suture, which was tied and cut along.  the posterior margin was marked with a #2-0 polydek suture, which was tied and cut.,the specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  on palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an allis forceps and excised with electrocautery and sent off the field as a separate specimen.  hemostasis was obtained with electrocautery.  good hemostasis was obtained.  the incision was closed in two layers.  the first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed vicryl.  the second layer consisted of steri-strips on the epidermis.  a pressure dressing of fluff, 4x4s, abds, and elastic bandage was applied.  the patient tolerated the surgery well.",23
"preoperative diagnoses:,1.  left carpal tunnel syndrome.,2.  stenosing tenosynovitis of right middle finger (trigger finger).,postoperative diagnoses:,1.  left carpal tunnel syndrome.,2.  stenosing tenosynovitis of right middle finger (trigger finger).,procedures:,1.  endoscopic release of left transverse carpal ligament.,2.  steroid injection, stenosing tenosynovitis of right middle finger.,anesthesia:  ,monitored anesthesia care with regional anesthesia applied by surgeon.,tourniquet time: , left upper extremity was 15 minutes.,operative procedure in detail:,  with the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  the arm was exsanguinated.  the tourniquet was elevated at 290 mmhg.  construction lines were made on the left palm to identify the ring ray.  a transverse incision was made in the palm between fcr and fcu, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  blunt dissection exposed the antebrachial fascia.  hemostasis was obtained with bipolar cautery.  a distal based window in the antebrachial fascia was then fashioned.  care was taken to protect the underlying contents.  a synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,hamate sounds were then used to palpate the hood of hamate.  the agee inside job was then inserted into the proximal incision.  the transverse carpal ligament was easily visualized through the portal.  using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  the distal end of the transverse carpal ligament was then identified in the window.  the blade was then elevated, and the agee inside job was withdrawn, dividing transverse carpal ligament under direct vision.  after complete division of transverse carpal ligament, the agee inside job was reinserted.  radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  one ml of celestone was then introduced into the carpal tunnel and irrigated free.  ,the wound was then closed with a running 3-0 prolene subcuticular stitch.  steri-strips were applied and a sterile dressing was applied over the steri-strips.  the tourniquet was deflated.  the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 ml of 1% plain xylocaine and 0.5 ml of depo-medrol 40 mg/ml.  a band-aid dressing was then applied.,the patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",26
"preoperative diagnosis:,  ectopic left testis.,postoperative diagnosis: , ectopic left testis.,procedure performed: , left orchiopexy.,anesthesia: , general.  the patient did receive ancef.,indications and consent: , this is a 16-year-old african-american male who had an ectopic left testis that severed approximately one-and-a-half years ago.  the patient did have an mri, which confirmed ectopic testis located near the pubic tubercle.  the risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  informed consent was on the chart at the time of procedure.,procedure details:  ,the patient did receive ancef antibiotics prior to the procedure.  he was then wheeled to the operative suite where a general anesthetic was administered.  he was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  the fascia was then dissected down both bluntly and sharply and hemostasis was maintained with bovie electrocautery.  the fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with metzenbaum scissors.  this was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  with this accomplished, the testis was then identified.  it was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,the cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  weitlaner retractor was placed to provide further exposure.  there was a small vein encountered posterior to the testis and this was then hemostated into place and cut with metzenbaum scissors and doubly ligated with #3-0 vicryl.  again hemostasis was maintained with ligation and bovie electrocautery with adequate mobilization of the spermatic cord and testis.  next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  this was taken down to approximately the two-thirds length of the left scrotal compartment.  once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  a skin incision through the scrotal skin and once again the skin edges were grasped with allis forceps and the dartos was then entered with the bovie electrocautery exposing the scrotal compartment.  once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the iris scissors.  a dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  a hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  with this accomplished, #3-0 prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  the sutures were then tied creating the orchiopexy.  the remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed monocryl in a horizontal mattress fashion interrupted sutures.  once again hemostasis was maintained with bovie electrocautery.  finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  external ring was then recreated and grasped on each side with hemostats and approximated with #3-0 vicryl in a running fashion cephalad to caudad.  once this was created, the created ring was inspected and there was adequate room for the cord.  there appeared to be no evidence of compression.  finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed vicryl in a running subcuticular fashion.  the patient had been injected with bupivacaine prior to closing the skin.  finally, the patient was cleansed.,the scrotal support was placed and plan will the for the patient to take keflex one tablet q.i.d. x7 days as well as tylenol #3 for severe pain and motrin for moderate pain as well as applying ice packs to scrotum.  he will follow up with dr. x in 10 to 14 days.  appointment will be made.",37
"preoperative diagnosis (es):, rectovaginal fistula.,postoperative diagnosis (es):, rectovaginal fistula.,procedure:, cpt code 57307 - closure of rectovaginal fistula, transperineal approach.,material forwarded to the laboratory for examination:, includes fistula tract.,estimated blood loss:, 25 ml.,indications:, the patient is a 27-year-old morbidly obese gravida three, para one, who was seen in consultation from dr. m's office, in the office of chattanooga gyn oncology on 01/12/06 regarding an obstetrically related rectovaginal fistula, dating from 1998. she had an episioproctotomy associated with the birth of her seven pound son in 1998 and immediately noted the spontaneous loss of gas and stool. she had her fistula repaired by dr. r in 2000 and did well for approximately one year, without complaint, when she again noted the spontaneous loss of stool and gas from her vagina. she has partial control if her stools are formed, but she has no control of her gas. she is a type 2 diabetic, with poorly controlled blood sugars at times, however, her diabetes has been fairly well controlled of late.,findings at the time of surgery:, she had a 1 cm fistulous tract, approximately 4 cm proximal to the vaginal introitus. this communicated directly with the low rectal vault. she had good rectal sphincter tone and a very thin perineal body. the fistulous tract was excised completely and intact. the underlying rectal mucosa was closed with chromic and the perineal body was reinforced and reconstructed. at the completion of the procedure, the repair is watertight, there were no other defects.,description of the operation:, the patient was taken to the operating room where she underwent general endotracheal anesthesia. she was then placed in the lithotomy position using candy-cane stirrups. the vulva and vagina were prepped and the patient was draped. a lacrimal duct probe was used to define the fistulous tract and a transperineal incision was made. the rectovaginal septum was developed and with an index finger in the rectum, the rectovaginal septum was easily defined. the fistulous tract was isolated and using the lacrimal duct probe, it was completely isolated. using electrocautery dissection on the pure cut mode, the rectal mucosa was entered in a circumferential fashion as was the vaginal mucosa. this allowed for removal of the fistulous tract intact, with both epithelial layers preserved. the perineum and rectum were irrigated vigorously and then the rectal mucosa was reapproximated with a running stitch of number 4-0 chromic. the rectal vault was distended with saline and the repair was watertight. the defect was irrigated, suctioned, inspected and found to be free of clot, blood or debris. the perineal body was reconstructed with reapproximation of the levator muscles, using a series of interrupted horizontal mattress stitches of number 2-0 vicryl. this allowed for excellent restoration of the perineal body. after this was accomplished, the defect was once again irrigated, suctioned, inspected, and found to be free of clot, blood or debris. the vaginal defect was closed with a running locking stitch of number 2-0 vicryl and the perineal incision was closed with a subcuticular stitch of number 2-0 vicryl. the patient was awakened and taken to the recovery room in stable condition, after having tolerated the procedure well.",37
"normal cataract surgery,procedure details: , the patient was taken to the operating room where the rand-stein anesthesia protocol was followed using alfentanil and brevital.  topical tetracaine drops were applied.  the operative eye was prepped and draped in the usual sterile fashion.  a lid speculum was inserted.,under the zeiss operating microscope, a lateral clear corneal approach was utilized.  a stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  a 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  a 5- to 5.5-mm anterior capsulorrhexis was created.  the nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  the nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  peripheral cortex was removed with the irrigation and aspiration handpiece.  the posterior capsule was polished.  the capsular bag was expanded with viscoelastic.  the implant was inspected under the microscope and found to be free of defects.  the implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  the trailing haptic was positioned with the cartridge system.  residual viscoelastic was removed from the anterior chamber and from behind the implant.  the corneal wound was hydrated with balanced salt solution.  the anterior chamber was fully re-formed through the side-port incision.  the wound was inspected and found to be watertight.  the intraocular pressure was adjusted as necessary.  the lid speculum was removed.  topical timoptic drops, eserine and dexacidin ointment were applied.  the eye was shielded.  the patient appeared to tolerate the procedure well and left the operating room in stable condition.  followup appointment is with dr. x on the first postoperative day.",37
"testicular ultrasound,reason for exam:  ,left testicular swelling for one day.,findings:  ,the left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  the right epididymis measures up to 9 mm.  there is a hydrocele on the right side.  normal flow is seen within the testicle and epididymis on the right.,the left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  the left testicle shows normal blood flow.  the left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  there is mild scrotal wall thickening.  a hydrocele is seen on the left side.,impression:,1.  hypervascularity of the left epididymis compatible with left epididymitis.,2.  bilateral hydroceles.",38
"procedure:,  upper endoscopy.,preoperative diagnosis: , dysphagia.,postoperative diagnosis:,1.  gerd, biopsied.,2.  distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  otherwise normal upper endoscopy.,medications: , fentanyl 125 mcg and versed 7 mg slow iv push.,indications: , this is a 50-year-old white male with dysphagia, which has improved recently with aciphex.,findings: , the patient was placed in the left lateral decubitus position and the above medications were administered.  the oropharynx was sprayed with cetacaine.  the endoscope was passed, under direct visualization, into the esophagus.  the squamocolumnar junction was irregular and edematous.  biopsies were obtained for histology.  there was a mild ring at the les, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  the entire gastric mucosa was normal, including a retroflexed view of the fundus.  the entire duodenal mucosa was normal to the second portion.  the patient tolerated the procedure well without complication.,impression:,1.  gastroesophageal reflux disease, biopsied.,2.  distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  otherwise normal upper endoscopy.,plan:,i will await the results of the biopsies.  the patient was told to continue maintenance aciphex and anti-reflux precautions.  he will follow up with me on a p.r.n. basis.",14
"preoperative diagnoses:,1.  right renal mass.,2.  hematuria.,postoperative diagnoses:,1.  right renal mass.,2.  right ureteropelvic junction obstruction.,procedures performed:,1.  cystourethroscopy.,2.  right retrograde pyelogram.,3.  right ureteral pyeloscopy.,4.  right renal biopsy.,5.  right double-j 4.5 x 26 mm ureteral stent placement.,anesthesia: , sedation.,specimen: , urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,indication:,  the patient is a 74-year-old male who was initially seen in the office with hematuria.  he was then brought to the hospital for other medical problems and found to still have hematuria.  he has a cat scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,procedure: ,after consent was obtained, the patient was brought to the operating room and placed in the supine position.  he was given iv sedation and placed in dorsal lithotomy position.  he was then prepped and draped in the standard fashion.  a #21 french cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  the patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  there were no masses or any other abnormalities noted other than the tuberculation.  attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  a retrograde pyelogram was performed.  upon visualization, there was no visualization of the upper collecting system on the right side.  at this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  the bladder was drained and the cystoscope was removed.  the rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  the ureteroscope was taken all the way through the proximal ureter just below the upj and there were noted to be no gross abnormalities.  the ureteroscope was removed and an amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  the ureteroscope was removed and a ureteral dilating sheath was passed over the amplatz wire into the right ureter under fluoroscopic guidance.  the amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  the ureteroscope was passed up to the upj at which point there was noted to be difficulty entering the ureter due to upj obstruction.  the wire was then again passed through the flexible scope and the flexible scope was removed.  a balloon dilator was then passed over the wire and the upj was dilated with balloon dilation.  the dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  the ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  once this was done, the wire was left in place and the ureteroscope was removed.  the cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  the stent was noted to be clear within the right renal pelvis as well as in the bladder.  the bladder was drained and the cystoscope was removed.  the patient tolerated the procedure well.  he will be transferred to the recovery room and back to his room.  it has been discussed with his primary physician that the patient will likely need a nephrectomy.  he will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on wednesday.",38
"reason for visit:,  weight loss evaluation.,history of present illness:,",15
"preoperative diagnoses:,1.  intrauterine pregnancy at term.,2.  arrest of dilation. ,postoperative diagnoses:,1.  intrauterine pregnancy at term.,2.  arrest of dilation.,procedure performed:,  primary low-transverse cesarean section.,anesthesia: , epidural.,estimated blood loss: , 1000 ml.,complications: , none.,findings:  ,female infant in cephalic presentation, op position, weight 9 pounds 8 ounces.  apgars were 9 at 1 minute and 9 at 5 minutes.  normal uterus, tubes, and ovaries were noted.,indications:  ,the patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation.  the patient progressed to 8 cm, at which time, pitocin was started.  she subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm.  a decision was made to proceed with a primary low transverse cesarean section.,the procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery.  informed consent was obtained prior to proceeding with the procedure.,procedure note:  ,the patient was taken to the operating room where epidural anesthesia was found to be adequate.  the patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt.  a pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the bovie.  the fascia was incised in the midline and extended laterally using mayo scissors.  kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using mayo scissors.  attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using mayo scissors.  the rectus muscles were dissected in the midline.,the peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder.  the bladder blade was inserted.  the vesicouterine peritoneum was identified with pickups and entered sharply using metzenbaum scissors.  this incision was extended laterally and the bladder flap was created digitally.  the bladder blade was reinserted.  the lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction.  clear fluid was noted.  the infant was subsequently delivered atraumatically.  the nose and mouth were bulb suctioned.  the cord was clamped and cut.  the infant was subsequently handed to the awaiting nursery nurse.  next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform.  subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted.  the uterus was exteriorized and cleared of all clots and debris.  the uterine incision was repaired in 2 layers using 0 chromic suture.  hemostasis was visualized.  the uterus was returned to the abdomen.,the pelvis was copiously irrigated.  the uterine incision was reexamined and was noted to be hemostatic.  the rectus muscles were reapproximated in the midline using 3-0 vicryl.  the fascia was closed with 0 vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples.  sponge, lap, and instrument counts were correct x2.  the patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.",37
"preoperative diagnosis (es):,1. endocarditis.,2. status post aortic valve replacement with st. jude mechanical valve.,3. pericardial tamponade.,postoperative diagnosis (es):,1. endocarditis.,2. status post aortic valve replacement with st. jude mechanical valve.,3. pericardial tamponade.,procedure:,1. emergent subxiphoid pericardial window.,2. transesophageal echocardiogram.,anesthesia:, general endotracheal.,findings:, the patient was noted to have 600 ml of dark bloody fluid around the pericardium. we could see the effusion resolve on echocardiogram. the aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. there was no evidence of endocarditis. the mitral valve leaflets moved normally with some mild mitral insufficiency.,description of the operation:, the patient was brought to the operating room emergently. after adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. a small incision was made at the bottom of the previous sternotomy incision. the subcutaneous sutures were removed. the dissection was carried down into the pericardial space. blood was evacuated without any difficulty. pericardial blake drain was then placed. the fascia was then reclosed with interrupted vicryl sutures. the subcutaneous tissues were closed with a running monocryl suture. a subdermal pds followed by a subcuticular monocryl suture were all performed. the wound was closed with dermabond dressing. the procedure was terminated at this point. the patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.",3
"history of present illness: , this is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  the patient also has a positive history of smoking in the past.  at the present time, he is admitted for continued,management of respiratory depression with other medical complications.  the patient was treated for multiple problems at jefferson hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  in addition, he also developed cardiac complications including atrial fibrillation.  the patient was evaluated by the cardiologist as well as the pulmonary service and urology.  he had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  he subsequently underwent cardiac arrest and he was resuscitated at that time.  he was intubated and placed on mechanical ventilatory support.  subsequent weaning was unsuccessful.  he then had a tracheostomy placed.,current medications:,1.  albuterol.,2.  pacerone.,3.  theophylline,4.  lovenox.,5.  atrovent.,6.  insulin.,7.  lantus.,8.  zestril.,9.  magnesium oxide.,10.  lopressor.,11.  zegerid.,12.  tylenol as needed.,allergies:,  penicillin.,past medical history:,1.  history of coal miner's disease.,2.  history of copd.,3.  history of atrial fibrillation.,4.  history of coronary artery disease.,5.  history of coronary artery stent placement.,6.  history of gastric obstruction.,7.  history of prostate cancer.,8.  history of chronic diarrhea.,9.  history of pernicious anemia.,10.  history of radiation proctitis.,11.  history of anxiety.,12.  history of ureteral stone.,13.  history of hydronephrosis.,social history: , the patient had been previously a smoker.  no other could be obtained because of tracheostomy presently.,family history: , noncontributory to the present condition and review of his previous charts.,systems review: , the patient currently is agitated.  rapidly moving his upper extremities.  no other history regarding his systems could be elicited from the patient.,physical exam:,general:  the patient is currently agitated with some level of distress.  he has rapid respiratory rate.  he is responsive to verbal commands by looking at the eyes.,vital signs:  as per the monitors are stable.,extremities:  inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage ii especially over the dorsum of the hands and forearm areas.  there is also edema of the forearm extending up to the mid upper arm area.  palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  there is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,impression:,1.  ulceration of bilateral upper extremities.,2.  cellulitis of upper extremities.,3.  lymphedema of upper extremities.,4.  other noninfectious disorders of lymphatic channels.,5.  ventilatory-dependent respiratory failure.",3
"chief complaint:,  right middle finger triggering and locking, as well as right index finger soreness at the pip joint.,history of occupational injury or illness:,  the patient has been followed elsewhere, and we reviewed his records.  essentially, he has had a trigger finger and a mucocyst, and he has had injections.  this has been going on for several months.  he is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain.  he is referred over here for evaluation regarding that.,significant past medical and surgical history:,general health/review of systems:  see h&p. ,allergies:  see h&p.,medications:  see h&p.,social history:  see h&p.,family history:  see h&p.,previous hospitalizations:  see h&p.,clinical assessment and findings:,musculoskeletal:  shows point tenderness to palpation to the right middle finger a1 pulley.  the right index finger has some small soreness at the pip joint, but at this time no obvious mucocyst.  he has flexion/extension of his fingers intact.  there is no crepitation at the wrist, forearm, elbow or shoulder with full range of motion.  contralateral arm exam for comparison reveals no focal findings.,neurological:  apb, epl and first dorsal interosseous 5/5.,laboratory, radiographic, and/or imaging tests orders & results:,special lab studies:  ,clinical impression:,1.  tendinitis, left middle finger.,2.  pip joint synovitis and mucocyst, but controlled on nonoperative treatment.,3.  middle finger trigger, failed nonoperative treatment, requiring a trigger finger release to the right middle finger.,evaluation/treatment plan:,  risks, benefits and alternatives were discussed.  all questions were answered.  no guarantees were made.  we will schedule for surgery.  we would like to move forward in order to help him significantly improve since he has failed injections.  all questions were answered.  followup appointment was given.",26
"vital signs:,  reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,constitutional: , normal appearance for chronological age, does not appear chronically ill.,heent: , the pupils are equal and reactive.  funduscopic examination is normal.  posterior pharynx is normal.  tympanic membranes are clear.,neck:  ,trachea is midline.  thyroid is normal.  the neck is supple.  negative nodes.,respiratory:,  lungs are clear to auscultation bilaterally.  the patient has a normal respiratory rate, no signs of consolidation and no egophony.  there are no retractions or secondary muscle use.  good bilateral breath sounds are noted.,cardiovascular: , no jugular venous distention or carotid bruits.  no increase in heart size to percussion.  there is no murmur.  normal s1 and s2 sounds are noted without gallop.,abdomen: , soft to palpation in all four quadrants.  there is no organomegaly and no rebound tenderness.  bowel sounds are normal.  obturator and psoas signs are negative.,genitourinary: , no bladder tenderness, negative flank pain.,musculoskeletal:,  extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,neurologic: , normal glasgow coma scale.  cranial nerves ii through xii appear grossly intact.  normal motor and cerebellar tests.  reflexes are normal.,heme/lymph:  ,no abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,psychiatric: , normal with no overt depression or suicidal ideations.",5
"indication for operation:,  right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,preoperative diagnosis:,  syndromic craniosynostosis.,postoperative diagnosis: , syndromic craniosynostosis.,title of operation: , anterior cranial vault reconstruction with fronto-orbital bar advancement.,specimens: , none.,drains: , one subgaleal drain exiting from the left posterior aspect of wound.,description of procedure:,  after satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  here, the proposed scalp incision was infiltrated with 1% xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  the two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  we then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  the pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  on the right, the orbital roof was jagged and abnormal and we had to repair a csf leak from where the dura was punctured by the orbital roof.  the orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  it was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  the bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 vicryl to secure back into place.  some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  the periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  the wounds were irrigated out.  a drain was left in posteriorly and then the wounds were closed in a routine manner using vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  the patient tolerated the procedure well and did receive blood transfusions.",37
"preoperative diagnosis: , t12 compression fracture with cauda equina syndrome and spinal cord compression.,postoperative diagnosis:,  t12 compression fracture with cauda equina syndrome and spinal cord compression.,operation performed: , decompressive laminectomy at t12 with bilateral facetectomies, decompression of t11 and t12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink synthes click'x system using 6.5 mm diameter x 40 mm length t11 screws and l1 screws, 7 mm diameter x 45 mm length.,anesthesia: , general endotracheal.,estimated blood loss:,  400 ml, replaced 2 units of packed cells.,preoperative hemoglobin was less than 10.,drains:,  none.,complications:,  none.,description of procedure: , with the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the t12-l1 interspace.  an incision was made over the posterior spinous process of t10, t11, t12, l1, and l2.  a weitlaner retractor was placed and cutting bovie current was used to incise the fascia overlying the dorsal spinous process of t10, t11, t12, l1, and l2.  an additional muscular ligamentous attachment was dissected free bilaterally with cutting bovie current osteotome and cobb elevator.  the cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at t12 was apparent.  initially, on the patient's left side, pedicle screws were placed in t11 and l1.  the inferior articular facet was removed at t11 and an awl placed at the proximal location of the pedicle.  placement confirmed with biplanar coaxial fluoroscopy.  the awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of t11.  a 40-mm click'x screw, 6.5 mm diameter with rod holder was then threaded into the t11 vertebral body.,attention was next turned to the l1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an am-8 dissecting tool, am attachment to the midas rex instrumentation.  the area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in l1.  using a pedicle probe, the pedicle was then probed to the mid body of l1 and a 7-mm diameter 45-mm in length click'x synthes screw with rod holder was placed in the l1 vertebral body.,at this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the mri findings of significant compression on the patient's ventral canal on the right side.  attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at t12 was noted be completely disrupted on a traumatic basis.  the anteroposterior spinous process ligament superior to the t12 was incised with cutting bovie current and the posterior spinous process at t12 removed with a leksell rongeur.  it was necessary to remove portion of the posterior spinous process at t11 for a full visualization of the involved laminar fractures at t12.,at this point, a laminectomy was performed using 45-degree kerrison rongeur, both 2 mm and 4 mm, and leksell rongeur.  there was an epidural hematoma encountered to the midline and left side at the mid portion of the t12 laminectomy and this was extending superiorly to the t11-t12 interlaminar space.  additionally, there was marked instability of the facets bilaterally at t12 and l1.  these facets were removed with 45-degree kerrison rongeur and leksell rongeur.  bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree kerrison rongeur until the thecal sac was completely decompressed.  the exiting nerve roots at t11 and t12 were visualized and followed with frazier dissectors, and these nerve roots were noted to be completely free.  hemostasis was controlled with bipolar coagulation.,at this point, a frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the t11-t12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  a #4 penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at t11 and l1 using the technique described for a left-sided pedicle screw placement.  the anatomic landmarks being the transverse process at t11, the inferior articulating facet, and the lateral aspect of the superior articular facet for t11 and at l1, the transverse process, the junction of the intra-articular process and the facet joint.,with the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  it was felt that distraction was not necessary.  a 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  the locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at t11-t12 or t12-l1 with excellent positioning of the rods and screws.  a crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,it should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at t11, t12, and l1 with am-8 dissecting tool, am attachment as well as the lateral aspects of the facet joints.  this was done bilaterally prior to placement of the rods.,following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 vicryl suture.  the fascia was closed with interrupted 0 vicryl suture, subcutaneous layer was closed with 2-0 vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted vicryl suture, and the skin approximated with staples.  the patient appeared to tolerate the procedure well without complications.",26
"admission diagnosis:,1. respiratory arrest.,2 . end-stage chronic obstructive pulmonary disease.,3. coronary artery disease.,4. history of hypertension.,discharge diagnosis:,1. status post-respiratory arrest.,2. chronic obstructive pulmonary disease.,3. congestive heart failure.,4. history of coronary artery disease.,5. history of hypertension.,summary:,  the patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. the patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. the patient has recently been admitted to the hospital with pneumonia and respiratory failure. the patient has been smoking up until three to four months previously. on the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. the patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,admission physical examination:,general: showed a well-developed, slightly obese man who was in extremis.,neck: supple, with no jugular venous distension.,heart: showed tachycardia without murmurs or gallops.,pulmonary: status showed decreased breath sounds, but no clear-cut rales or wheezes.,extremities: free of edema.,hospital course:,  the patient was admitted to the special care unit and intubated. he received intravenous antibiotic therapy with levaquin. he received intravenous diuretic therapy. he received hand-held bronchodilator therapy. the patient also was given intravenous steroid therapy with solu-medrol. the patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. he continued to be quite dyspneic, with wheezes as well as basilar rales. after pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. with this, the patient was placed on increased doses of lisinopril and digoxin, with improvement of his respiratory status. on the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. it was, therefore, felt that the patient was stable for further management on an outpatient basis.,diagnostic data:,  the patient’s admission laboratory data was notable for his initial blood gas, which showed a ph of 7.02 with a pco2 of 118 and a po2 of 103. the patient’s electrocardiogram showed nonspecific st-t wave changes. the patent’s cbc showed a white count of 24,000, with 56% neutrophils and 3% bands.,disposition:,  the patient was discharged home.,discharge instructions:,  his diet was to be a 2 grams sodium, 1800 calorie ada diet. his medications were to be prednisone 20 mg twice per day, theo-24 400 mg per day, furosemide 40 mg 1-1/2 tabs p.o. per day; acetazolamide 250 mg one p.o. per day, lisinopril 20 mg. one p.o. twice per day, digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., k-dur 60 meq p.o. b.i.d. he was also to use a ventolin inhaler every four hours as needed, and azmacort four puffs twice per day. he was asked to return for follow-up with dr. x in one to two weeks. arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.",10
"preoperative diagnosis: ,incomplete abortion.,postoperative diagnosis: ,incomplete abortion.,procedure performed:, suction dilation and curettage.,anesthesia:  ,general and nonendotracheal by dr. x.,estimated blood loss: , less than 200 cc.,specimens: , endometrial curettings.,drains: , none.,findings:  ,on bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  there was a large amount of tissue obtained on the procedure.,procedure:  ,the patient was taken to the operating room where a general anesthetic was administered.  she was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  next, a weighted speculum was placed in the vagina.  the anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  a size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  two passes were made with the suction curettage.  next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  after the procedure, the vulsellum tenaculum was removed.  the cervix was seemed to be hemostatic.  the weighted speculum was removed.  the patient was given 0.25 mg of methergine im approximately half-way through the procedure.  after the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  it is now approximately eight to ten-week size.  the patient was taken from the operating room in stable condition after she was cleaned.  she will be discharged on today.  she was given methergine, motrin, and doxycycline for her postoperative care.  she will follow-up in one week in the office.",23
"preoperative diagnosis:,  cervical myelopathy secondary to very large disc herniations at c4-c5 and c5-c6.,postoperative diagnosis: , cervical myelopathy secondary to very large disc herniations at c4-c5 and c5-c6.,procedure performed:,1.  anterior cervical discectomy, c4-c5 and c5-c6.,2.  arthrodesis, c4-c5 and c5-c6.,3.  partial corpectomy, c5.,4.  machine bone allograft, c4-c5 and c5-c6.,5.  placement of anterior cervical plate with a zephyr c4 to c6.,6.  fluoroscopic guidance.,7.  microscopic dissection.,anesthesia:,  general.,estimated blood loss: , 60 ml.,complications: , none.,indications:,  this is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  he has also noted to have cord signal at the c4-c5 level secondary to a very large disc herniation that came behind the body at c5 as well and as well as a large disc herniation at c5-c6.  risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  he understood and wished to proceed.,description of procedure: , the patient was brought to the operating room and placed in the supine position.  preoperative antibiotics were given.  the patient was placed in the supine position with all pressure points noted and well padded.  the patient was prepped and draped in standard fashion.  an incision was made approximately above the level of the cricoid.  blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  we then placed needle into the disc spaces and was found to be at c5-c6.  distracting pins were placed in the body of c4 and in to the body of c6.  the disc was then completely removed at c4-c5.  there was very significant compression of the cord.  this was carefully removed to avoid any type of pressure on the cord.  this was very severe and multiple free fragments were noted.  this was taken down to the level of ligamentum.  both foramen were then also opened.  other free fragments were also found behind the body of c5, part of the body of c5 was taken down to assure that all of these were removed.  the exact same procedure was done at c5-c6; however, if there were again free fragments noted, there was less not as severe compression at the c4-c5 area.  again part of the body at c5 was removed to make sure that there was no additional constriction.  both nerve roots were then widely decompressed.  machine bone allograft was placed into the c4-c5 as well as c5-c6 and then a zephyr plate was placed in the body of c4 and to the body of c6 with a metal pin placed into the body at c5.  excellent purchase was obtained.  fluoroscopy showed good placement and meticulous hemostasis was obtained.  fascia was closed with 3-0 vicryl, subcuticular 3-0 dermabond for skin.  the patient tolerated the procedure well and went to recovery in good condition.",37
"exam: , ct chest with contrast.,reason for exam: , pneumonia, chest pain, short of breath, and coughing up blood.,technique: , postcontrast ct chest 100 ml of isovue-300 contrast.,findings: , this study demonstrates a small region of coalescent infiltrates/consolidation in the anterior right upper lobe.  there are linear fibrotic or atelectatic changes associated with this.  recommend followup to ensure resolution.  there is left apical scarring.  there is no pleural effusion or pneumothorax.  there is lingular and right middle lobe mild atelectasis or fibrosis.,examination of the mediastinal windows disclosed normal inferior thyroid.  cardiac and aortic contours are unremarkable aside from mild atherosclerosis.  the heart is not enlarged.  there is no pathologic adenopathy identified in the chest including the bilateral axillary and hilar regions.,very limited assessment of the upper abdomen demonstrates no definite abnormalities.,there are mild degenerative changes in the thoracic spine.,impression:,1.anterior small right upper lobe infiltrate/consolidation.  recommend followup to ensure resolution given its consolidated appearance.,2.bilateral atelectasis versus fibrosis.",3
"a 1 cm infraumbilical skin incision was made.  through this a veress needle was inserted into the abdominal cavity.  the abdomen was filled with approximately 2 liters of co2 gas.  the veress needle was withdrawn.  a trocar sleeve was placed through the incision into the abdominal cavity.  the trocar was withdrawn and replaced with the laparoscope.  a 1 cm suprapubic skin incision was made.  through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  the trocar was withdrawn and replaced with a probe.,the patient was placed in trendelenburg position, and the bowel was pushed out of the pelvis.  upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  the probe was withdrawn and replaced with the bipolar cautery instrument.  the right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  electrical current was applied to the tube at this point and fulgurated.  the tube was then regrasped just distal to this and refulgurated.  it was then regrasped just distal to the lateral point and refulgurated again.  the same procedure was then carried out on the opposite tube.  the bipolar cautery instrument was withdrawn and replaced with the probe.  the fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  the upper abdomen was visualized, and the liver surface was normal.  the gas was allowed to escape from the abdomen, and the instruments were removed.  the skin incisions were repaired.  the instruments were removed from the vagina.,there were no complications to the procedure.  blood loss was minimal.  the patient went to the postanesthesia recovery room in stable condition.",23
"preoperative diagnosis: , rotated cuff tear, right shoulder.,postoperative diagnoses:,1.  rotated cuff tear, right shoulder.,2.  glenoid labrum tear.,procedure performed:,1.  arthroscopy with arthroscopic glenoid labrum debridement.,2.  subacromial decompression.,3.  rotator cuff repair, right shoulder.,specifications:,  intraoperative procedure was done at inpatient operative suite, room #1 at abcd hospital.  this was done under interscalene and subsequent general anesthetic in the modified beach chair position.,history and gross findings: , the patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  he was completely refractory to conservative outpatient therapy.  after discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,intraarticularly, the joint was observed.  there was noted to be a degenerative glenoid labrum tear.  the biceps complex was otherwise intact.  there were minimal degenerative changes at the glenohumeral joint.  rotator cuff tear was appreciated on the inner surface.  subacromially, the same was true.  this was an elliptical to v-type tear.  the patient has a grossly positive type iii acromion.,operative procedure: , the patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the anesthesia department.  he was safely placed in modified beach chair position.  he was prepped and draped in the usual sterile manner.  portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  debridement was carried out to the glenoid labrum.  the biceps was probed and noted to be intact.  undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,after this, instrumentation was removed.  the scope was placed subacromially and a lateral portal created.  gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  an anterolateral portal was created.  sutures were placed via express silk as well as other sutures with a #2 fiber wire.  with passing of the suture, they were tied with a slip-tight knot and then two half stitches.  there was excellent reduction of the tear.  superolateral portal was then created.  a #1 mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  the implant was put into place.  the loop was grabbed and it was impacted in the previously drilled holes.  there was excellent reduction of the tear.,trial range of motion was carried out and seemed to be satisfactory.,prior to this, a subacromial decompression was accomplished after release of ca ligament with the vapor bovie.  a 4.8 motorized barrel burr was utilized to sequentially take this down from the type iii acromion to a flat type i acromion.,after all was done, copious irrigation was carried out throughout the joint.  gross bursectomy lightly was carried out to remove all bony elements.  a pain buster catheter was placed through a separate portal and cut to length.  0.5% marcaine was instilled after portals were closed with #4-0 nylon.  adaptic, 4 x 4s, abds, and elastoplast tape placed for dressing.  the patient was ultimately transferred to his cart and pacu in apparent satisfactory condition.  expected surgical prognosis of this patient is fair.",37
"diagnosis at admission: , hypothermia.,diagnoses on discharge,1. hypothermia.,2. rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. organic brain syndrome.,4. seizure disorder.,5. adrenal insufficiency.,6. hypothyroidism.,7. anemia of chronic disease.,hospital course:  ,the patient was admitted through the emergency room.  he was admitted to the intensive care unit.  he was rewarmed and had blood, sputum, and urine cultures done.  he was placed on iv rocephin.  his usual medications of dilantin and depakene were given.  the patient's hypertension was treated with fluid boluses.  the patient was empirically placed on synthroid and hydrocortisone by dr. x.  blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  h&h was stable at 33.3/10.9 and platelets of 80,000.  white blood cell counts were normal, differential was normal.  tsh was 3.41.  free t4 was 0.9.  dr. x felt this was consistent with secondary hypothyroidism and recommended synthroid replacement.  a cortisol level was obtained prior to administration of hydrocortisone.  this was 10.9 and that was not a fasting level.  dr. x felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and florinef.  the patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his florinef 0.1 mg on monday, wednesday, and friday.  the patient was started back on his tube feeds.  he tolerated these poorly with residuals.  reglan was increased to 10 mg q.6 h. and erythromycin is being added.  the patient's temperature has been stable in the 94 to 95 range.  other vital signs have been stable.  his urine output has been diminished.  an external jugular line was placed in the intensive care unit.  the patient's legal guardian, janet sanchez in albuquerque has requested he be transported there.  as per several physicians in albuquerque and dr. y, an internist, we will accept him once we have a nursing home available to him.  he is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in albuquerque.  his prognosis is poor.",10
"chief complaint:,  the patient is a 49-year-old caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,history of present illness:, the patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. he has made multiple visits in the past. today, the patient presents himself in severe respiratory distress. his wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,today, his symptoms worsened and she brought him to the emergency room. to the best of her knowledge, there has been no fever. he has persistent chronic cough, as always. more complete history cannot be taken because of the patient’s acute respiratory decompensation.,past medical history:,  hypertension and emphysema.,medications:,  lotensin and some water pill as well as, presumably, an atrovent inhaler.,allergies:,  none are known.,habits:,  the patient is unable to cooperate with the history.,social history:,  the patient lives in the local area with his wife.,review of body systems:,  unable, secondary to the patient’s condition.,physical examination:,vital signs: temperature 96 degrees, axillary. pulse 128. respirations 48. blood pressure 156/100. initial oxygen saturations on room air are 80.,general: reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,heent: head is normocephalic and atraumatic.,neck: the neck is supple without obvious jugular venous distention.,lungs: auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,heart: cardiac examination reveals sinus tachycardia, without pronounced murmur.,abdomen: soft to palpation.,extremities: without edema.,diagnostic data:,  white blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, co2 44, bun 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. troponin is 0.11. urinalysis reveals yellow clear urine. specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. no white cells and 0-2 red cells.,chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,critical care note:,  critical care one hour.,shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. although o2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. he became progressively more rapidly obtunded. the patient did receive one gram of magnesium sulfate shortly after his arrival, and the bipap apparatus was being readied for his use. however, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. the bipap apparatus was briefly placed while supplies and medications were assembled for intubation. it was noted that even with the bipap apparatus, in the duration of time which was required for transfer of oxygen tubing to the bipap mask, the patient’s o2 saturations rapidly dropped to the upper 60 range.,all preparations for intubation having been undertaken, succinylcholine was ordered, but was apparently unavailable in the department. as the patient was quite obtunded, and while the dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. however, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of dacuronium 10 mg. after approximately two minutes, another attempt at intubation was successful. the cords were noted to be covered with purulent exudates at the time of intubation.,the endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his o2 saturations rapidly rose to the 90-100% range.,chest x-ray demonstrated proper placement of the tube. the patient was given 1 mg of versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,because of a complaint of chest pain, which i myself did not hear, during the patient’s initial triage elevation, a trial of tridil was begun. as the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. however, after administration of the dacuronium and versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,because of concern regarding pneumonia or sepsis, the patient received one gram of rocephin intravenously shortly after the intubation. a nasogastric and foley were placed, and an arterial blood gas was drawn by respiratory therapy. dr. x was contacted at this point regarding further orders as the patient was transferred to the intensive care unit to be placed on the ventilator there. the doctor’s call was transferred to the intensive care unit so he could leave appropriate orders for the patient in addition to my initial orders, which included albuterol or atrovent q. 2h. and levaquin 500 mg iv, as well as solu-medrol.,critical care note terminates at this time.,emergency department course:,  see the critical care note.,medical decision making (differential diagnosis):,  this patient has an acute severe decompensation with respiratory failure. given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. similarly, it would be difficult to rule out sepsis. myocardial infarction cannot be excluded.,coordination of care:,  dr. x was contacted from the emergency room and asked to assume the patient’s care in the intensive care unit.,final diagnosis:,  respiratory failure secondary to severe chronic obstructive pulmonary disease.,discharge instructions:, the patient is to be transferred to the intensive care unit for further management.",12
"preoperative diagnoses:,1.  dysphagia.,2.  right parapharyngeal hemorrhagic lesion.,postoperative diagnoses:,1.  dysphagia with no signs of piriform sinus pooling or aspiration.,2.  no parapharyngeal hemorrhagic lesion noted.,3.  right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,procedure performed: ,fiberoptic nasolaryngoscopy.,anesthesia: , none.,complications: , none.,indications for procedure: , the patient is a 93-year-old caucasian male who was admitted to abcd general hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ent was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to lma intubation.  the patient subsequently resolved with his dysphagia and workup of speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  this is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,procedure details: ,the patient was brought in the semi-fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  the scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  the patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  there were no signs of any obstruction.  the epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  the patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  the scope was then pulled out and the patient tolerated the procedure well.  at this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.",11
"preoperative diagnosis:,  lumbar spondylosis.,postoperative diagnosis:,  lumbar spondylosis.,operation performed:,  lumbar facet injections done under fluoroscopic control.,anesthesia:,  local and iv.,complications:,  none.,description of procedure:  ,after proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place.  the skin was prepped and draped in a sterile classical fashion.  the patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter.  the patient was given oxygen, intravenous sedation and analgesics as needed.  the facets were identified and marked under fluoroscopic control by rotating the c-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's ""scottie dog"" and the opening of the facet.,after each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets.  a 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique.  after negative aspiration, 0.25 - 0.5 cc of omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule.  after another negative aspiration, 1cc of a 10cc solution of marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet.  the patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.",27
"preoperative diagnosis: , angina and coronary artery disease.,postoperative diagnosis: , angina and coronary artery disease.,name of operation: , coronary artery bypass grafting (cabg) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, st. jude proximal anastomosis used for vein graft.  off-pump medtronic technique for left internal mammary artery, and a bivad technique for the circumflex.,anesthesia: , general.,procedure details: , the patient was brought to the operating room and placed in the supine position upon the table.  after adequate general anesthesia, the patient was prepped with betadine soap and solution in the usual sterile manner.  elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,a midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  pericardial and thymus fat pad was divided.  the left internal mammary artery was harvested and spatulated for anastomosis.  heparin was given.,vein resected from the thigh, side branches secured using 4-0 silk and hemoclips.  the thigh was closed multilayer vicryl and dexon technique.  a pulsavac wash was done, drain was placed.,the left internal mammary artery is sewn to the left anterior descending using 7-0 running prolene technique with the medtronic off-pump retractors.  after this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  medtronic retractors used to expose the circumflex.  prior to going on pump, we stapled the vein graft in place to the aorta.,then, on pump, we did the distal anastomosis with a 7-0 running prolene technique.  the right side graft was brought to the posterior descending artery using running 7-0 prolene technique.  deairing procedure was carried out.  the bulldogs were removed.  the patient maintained good normal sinus rhythm with good mean perfusion.  the patient was weaned from cardiopulmonary bypass.  the arterial and venous lines were removed and doubly secured.  protamine was delivered.  meticulous hemostasis was present.  platelets were given for coagulopathy.  chest tube was placed and meticulous hemostasis was present.  the anatomy and the flow in the grafts was excellent.  closure was begun.,the sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 vicryl sutures in double-layer technique.  the skin was closed with subcuticular 4-0 dexon suture technique.  the patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,we minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.",3
"preoperative diagnosis: , thrombosed arteriovenous shunt left forearm.,postoperative diagnosis:  ,thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,procedure:  ,thrombectomy av shunt, left forearm and patch angioplasty of the venous anastomosis.,anesthesia: , local.,skin prep: , betadine.,drains: , none.,procedure technique:  ,the left arm was prepped and draped.  xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop.  the runoff vein was dissected out and encircled with the vessel loop as well.  a longitudinal incision was made over the venous anastomosis.  there was a narrowing in the area and slightly the incision was extended more proximally.  there was good back bleeding from the vein as well as bleeding from the more distal vein.  these were occluded with noncrushing debakey clamps and the patient was given 5000 units of heparin intravenously.  a #4 fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established.  there was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator.  the fogarty catheter was then passed up the vein, but no clot was obtained.  a patch ptfe material was fashioned and was sutured over the graftotomy with running 6-0 gore-tex suture.  clamps were removed and flow established.  a thrill was easily palpable.  hemostasis was achieved and the wound was irrigated and closed with 3-0 vicryl subcutaneous suture followed by 4-0 nylon on the skin.  a sterile dressing was applied.  the patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.  sponge, instrument and needle counts were reported as correct.",37
"initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  this incision was carried down to the area of the previous vasectomy.  a towel clip was placed around this.  next the scarred area was dissected free back to normal vas proximally and distally.  approximately 4 cm of vas was freed up.  next the vas was amputated above and below the scar tissue.  fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends.  both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully.  after accomplishing this, fluid could be milked from the proximal vas which was encouraging.,next the reanastomosis was performed.  three 7-0 prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen.  this was all done with 3.5 loupe magnification.  next the vas ends were pulled together by tying the sutures.  a good reapproximation was noted.  next in between each of these sutures two to three of the 7-0 prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,there was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum.  the subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,next an identical procedure was done on the left side.,the patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition.  antibiotic ointment, fluffs, and a scrotal support were placed.",37
"preoperative diagnosis:  ,status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,postoperative diagnosis: , status post spontaneous hemorrhage from medial temporal arteriovenous malformation with arteriographic evidence of associated aneurysm.,operation: , right pterional craniotomy with obliteration of medial temporal arteriovenous malformation and associated aneurysm and evacuation of frontotemporal intracerebral hematoma.,anesthesia: , endotracheal.,estimated blood loss: , 250 ml,replacements:  ,3 units of packed cells.,drains:,  none.,complications: , none.,procedure:  ,with the patient prepped and draped in the routine fashion in the supine position with the head in a mayfield headrest, turned 45 degrees to the patient's left and a small roll placed under her right shoulder and hip, the previously made pterional incision was reopened and extended along its posterior inferior limb to the patient's zygoma.  additional aspect of the temporalis muscle and fascia were incised with cutting bovie current with effort made to preserve the posterior limb of the external carotid artery.  the scalp and temporalis muscle were then retracted anteroinferiorly with 0 silk sutures, attached rubber bands and allis clamps and similar retraction of the posterior aspect of temporalis was retracted with 0 silk suture, attached with rubber bands and allis clamps.  the bone flap, which had not been fixed in place was removed.  an additional portion of the temporofrontal bone based at the zygoma was removed with a b1 dissecting tool, b1 attached to the midas rex instrumentation.  further bone removal was accomplished with leksell rongeur, and hemostasis controlled with the use of bone wax.,at this point, a retractor was placed along the frontal lobe for visualization of the perichiasmatic cistern with visualization made of the optic nerve and carotid artery.  it should be noted that cottonoid paddies were placed over the brain to protect the cortical surface of the brain both underneath the retractor and the remainder of the exposed cortex.  the sylvian fissure was then dissected with the dissection description being dictated by dr. x.,following successful splitting of the sylvian fissure to its apparent midplate, attention was next turned to the temporal tip where the approximate location of the cerebral aneurysm noted on ct angio, as well as conventional arteriography was noted and a peel incision was made extending from the temporal tip approximately 3 cm posterior.  this was enlarged with bipolar coagulation and aspiration and inferior dissection accomplished under the operating microscope until the dome of, what appeared to be, an aneurysm could be visualized.,dissection around the dome with bipolar coagulation and aspiration revealed a number of abnormal vessels, which appeared to be involved with the aneurysm at its base and these were removed with bipolar coagulation.  until circumferential dissection revealed 1 major arterial supply to the base of the aneurysm, this was felt to be able to be handled with bipolar coagulation, which was done and the vessel then cut with microscissors and the aneurysm removed in toto.,attention was next turned to the apparent nidus of the arteriovenous malformation, which was somewhat medial and inferior to the aneurysm and the nidus was then dissected with the use of bipolar coagulation and aspiration microscissors as further described by dr. x. with removal of the arteriovenous malformation, attention was then turned to the previous frontal cortical incision, which was the site of partial decompression of the patient's intracerebral hematoma on the day of her admission.  self-retaining retractors were placed within this cortical incision, and the hematoma cavity entered with additional hematoma removed with general aspiration and irrigation.  following removal of additional hematoma, the bed of the hematoma site was lined with surgicel.  irrigation revealed no further active bleeding, and it was felt that at this time both the arteriovenous malformation, associated aneurysm, and intracerebral hematoma had been sequentially dealt with.,the cortical surface was then covered with surgicel and the dura placed over the surface of the brain after coagulation of the dural edges, the freeze dried fascia, which had been used at the time of the 1st surgery was replaced over the surface of the brain with additional areas of cortical exposure covered with a duraguard.  the 2nd bone flap from the inferior frontotemporal region centered along the zygoma was reattached to the initial bone flap at 3 sites using a small 2-holed plate and 3-mm screws and the portable minidriver.,with this, return of the inferior plate accomplished, it was possible to reposition the bone flaps into their initial configuration, and attachments were secured anterior and posterior with somewhat longer 2-holed plates and 3-mm screws to the frontal and posterior temporal parietal region.  the wound was then closed.  it should be noted that a pledget of gelfoam had been placed over the entire dural complex prior to returning the bone flap.  the wound was then closed by approximating the temporalis muscle with 2-0 vicryl suture, the fascia was closed with 2-0 vicryl suture, and the galea was closed with 2-0 interrupted suture, and the skin approximated with staples.  the patient appeared to tolerate the procedure well without complications.",37
"chief complaint: , left breast cancer.,history:,  the patient is a 57-year-old female, who i initially saw in the office on 12/27/07, as a referral from the tomball breast center.  on 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  the biopsy returned showing infiltrating ductal carcinoma high histologic grade.  the patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  she prior to that area, denied any complaints.  she had no nipple discharge.  no trauma history.  she has had been on no estrogen supplementation.  she has had no other personal history of breast cancer.  her family history is positive for her mother having breast cancer at age 48.  the patient has had no children and no pregnancies.  she denies any change in the right breast.  subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with dr. x and radiation oncology consultation with dr. y.  i have discussed the case with dr. x and dr. y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  the patient's metastatic workup has otherwise been negative with mri scan and ct scanning.  the mri scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  ct scan of the neck, chest, and abdomen is negative for metastatic disease.,past medical history:,  previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,medications:,  she is currently on omeprazole for reflux and indigestion.,allergies:,  she has no known drug allergies.,review of systems:,  negative for any recent febrile illnesses, chest pains or shortness of breath.  positive for restless leg syndrome.  negative for any unexplained weight loss and no change in bowel or bladder habits.,family history:,  positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,social history:  ,the patient works as a school teacher and teaching high school.,physical examination,general:  the patient is a white female, alert and oriented x 3, appears her stated age of 57.,heent:  head is atraumatic and normocephalic.  sclerae are anicteric.,neck:  supple.,chest:  clear.,heart:  regular rate and rhythm.,breasts:  exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  there are no nipple retractions.  no skin dimpling.  there is some, at the time of the office visit, ecchymosis from recent biopsy.  there is no axillary adenopathy.  the remainder of the left breast is without abnormality.  the right breast is without abnormality.  the axillary areas are negative for adenopathy bilaterally.,abdomen:  soft, nontender without masses.  no gross organomegaly.  no cva or flank tenderness.,extremities:  grossly neurovascularly intact.,impression: , the patient is a 57-year-old female with invasive ductal carcinoma of the left breast, t1c, nx, m0 left breast carcinoma.,recommendations: , i have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  we have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  the possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  the procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  local numbness, paresthesias or chronic pain was explained.  the patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  she was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  i believe the patient has given full informed consent and desires to proceed with the above.",16
"subjective:,  the patient is a 65-year-old man with chronic prostatitis who returns for recheck.  he follow with dr. xyz about every three to four months.  his last appointment was in may 2004.  has had decreased libido since he has been on proscar.  he had tried viagra with some improvement.  he has not had any urinary tract infection since he has been on proscar.  has nocturia x 3 to 4.,past medical history/surgeries/hospitalizations:  ,soon after birth for treatment of an inperforated anus and curvature of the penis.  at the age of 70 had another penile operation.  at the age of 27 and 28 he had repeat operations to correct this.  he did have complications of deep vein thrombosis and pulmonary embolism with one of those operations.  he has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus.  in january of 1991 underwent cystoscopy.  he was hospitalized in 1970 for treatment of urinary tract infection.  in 2001, left rotator cuff repair with acromioplasty and distal clavicle resection.  in 2001, colonoscopy that was normal.  in 2001, prostate biopsy that showed chronic prostatitis.  in 2003, left inguinal hernia repair with mesh.,medications:,  bactrim ds one pill a day, proscar 5 mg a day, flomax 0.4 mg daily.  he also uses metamucil four times daily and stool softeners for bedtime.,allergies:,  cipro.,family history:,  father died from ca at the age of 79.  mother died from postoperative infection at the age of 81.  brother died from pancreatitis at the age of 40 and had a prior history of mental illness.  father also had a prior history of lung cancer.  mother had a history of breast cancer.  father also had glaucoma.  he does not have any living siblings.  friend died a year and half ago.,personal history:,  negative for use of alcohol or tobacco.  he is a professor at college and teaches history and bible.,review of systems:,eyes, nose and throat:  wears eye glasses.  has had some gradual decreased hearing ability.,pulmonary:  denies difficulty with cough or sputum production or hemoptysis.,cardiac:  denies palpitations, chest pain, orthopnea, nocturnal dyspnea, or edema.,gastrointestinal:  has had difficulty with constipation.  he denies any positive stools.  denies peptic ulcer disease.  denies reflux or melena.,genitourinary:  as mentioned previously.,neurologic:  without symptoms.,bones and joints:  he has had occasional back pain.,hematologic:  occasionally has had some soreness in the right axillary region, but has not had known lymphadenopathy.,endocrine:  he has not had a history of hypercholesterolemia or diabetes.,dermatologic:  without symptoms.,immunization:  he had pneumococcal vaccination about three years ago.  had an adult dt immunization five years ago.,physical examination:,vital signs:  weight:  202.8 pounds.  blood pressure:  126/72.  pulse:  60.  temperature:  96.8 degrees.,general appearance:  he is a middle-aged man who is not in any acute distress.,heent:  eyes:  pupils are equally regular, round and reactive to light.  extraocular movements are intact without nystagmus.  visual fields were full to direct confrontation.  funduscopic exam reveals middle size disc with sharp margins.  ears:  tympanic membranes are clear.  mouth:  no oral mucosal lesions are seen.,neck:  without adenopathy or thyromegaly.,chest:  lungs are resonant to percussion.  auscultation reveals normal breath sounds.,heart:  normal s1 and s2 without gallops or rubs.,abdomen:  without tenderness or masses to palpation.,genitorectal exam:  not repeated since these have been performed recently by dr. tandoc.,extremities:  without edema.,neurologic:  reflexes are +2 and symmetric throughout.  babinski is negative and sensation is intact.  cranial nerves are intact without localizing signs.  cerebellar tension is normal.,impression/plan:,1.  chronic prostatitis.  he has been stable in this regard.,2.  constipation.  he is encouraged to continue with his present measures.  additionally, a tsh level will be obtained.,3.  erectile dysfunction.  testosterone level and comprehensive metabolic profile will be obtained.,4.  anemia.  cbc will be rechecked.  additional stools for occult blood will be rechecked.",38
"exam:,mri right knee without gadolinium,clinical:,this is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. patient has had prior lateral meniscectomy in 2001.,findings:,examination was performed on 8/3/05,normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,there is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). there is no displaced tear or displaced meniscal fragment.,there is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,normal posterior cruciate ligament.,normal medial collateral ligament.,there is a strain of the popliteus muscle and tendon without complete tear.,there is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). there is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. normal quadriceps and patellar tendons.,there is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. there is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). there is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,the patellofemoral joint is congruent without patellar tilt or subluxation. normal medial and lateral patellar retinacula. there is a joint effusion.,impression:,changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,mild anterior cruciate ligament interstitial sprain.,there is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible second fracture which should be correlated with radiographs.,",26
"chief complaint:,  dental pain.,history of present illness:,  this is a 27-year-old female who presents with a couple of days history of some dental pain.  she has had increasing swelling and pain to the left lower mandible area today.  presents now for evaluation.,past medical history: , remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  she has chronic pain in general and is followed by dr. x.,review of systems: , otherwise, unremarkable.  has not noted any fever or chills.  however she, as mentioned, does note the dental discomfort with increasing swelling and pain.  otherwise, unremarkable except as noted.,current medications: , please see list.,allergies: , iodine, fish oil, flexeril, betadine.,physical examination: , vital signs:  the patient was afebrile, has stable and normal vital signs.  the patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  heent:  unremarkable.  i do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  there is no neck adenopathy.  oral mucosa is moist and well hydrated.  dentition looks to be in reasonable condition.  however, she definitely is tender to percussion on the left lower first premolar.  i do not see any huge cavity or anything like that.  no real significant gingival swelling and there is no drainage noted.  none of the teeth are tender to percussion.,procedure:,  dental nerve block.  using 0.5% marcaine with epinephrine, i performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  i have then written a prescription for penicillin and vicodin for pain.,impression: , acute dental abscess.,assessment and plan:  ,the patient needs to follow up with the dentist for definitive treatment and care.  she is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  however, outpatient followup should be adequate.  she is discharged in stable condition.",12
"informant:,  dad on phone.  transferred from abcd memorial hospital, rule out sepsis.,history:  ,this is a 3-week-old, nsvd, caucasian baby boy transferred from abcd memorial hospital for rule out sepsis and possible congenital heart disease.  the patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  all the sepsis workup was done, cbc, ua, lp, and cmp, and since a murmur was noted 2/5, he also had an echo done.  the patient was put on ampicillin and cefotaxime.  echo results came back and they showed patent foramen ovale/asd with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  the patient was n.p.o. when he came in.  he was on 3/4 l of oxygen.  according to the note, it conveyed that he had some subcostal retractions.  on arriving here, baby looks very healthy.  he has no subcostal retractions.  he is not requiring any oxygen and he is positive for urine and stool.  the stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ed called that case is a direct admit.,review of systems:  ,the patient supposedly had fever, some weight loss, poor appetite.  the day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  according to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  he usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  mom gave baby some pedialyte.,past medical history:,  none.,hospitalizations:,  recent transfer from abcd for the rule out sepsis and heart disease.,birth history:  ,born on 08/23/2006 at memorial hospital, nsvd, no complications.  hospital stay 24 hours.  breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,family history:,  none.,surgical history: , none.,social history:  ,lives with mom and dad.  dad is a service manager at gmc; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  they usually visit to a ranch, but not recently.  no sick contact and no travel.,medications: , has been on vancomycin, cefotaxime, and ampicillin.,allergies:,  no allergies.,diet:,  breast feeds q.2h.,immunizations: , no immunizations.,physical examination:,vital signs:  temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,measurements:  weight 3.725 kg.,general:  alert and comfortable and sleeping.,skin:  no rash.,heent:  intact extraocular movements.  perrla.  no nasal discharge.  no nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,neck:  soft, nontender, supple.,chest:  ctap.,gi:  bowel sounds present.  nontender, nondistended.,gu:  bilaterally descended testes.,back:  straight.,neurologic:  nonfocal.,extremities:  no edema.  bilateral pedal pulses present and upper arm pulses are also present.,laboratory data:,  as drawn on 09/13/2006 at abcd showed wbc 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  sodium 140, potassium 4.9, chloride 105, bicarbonate 28, bun 7, creatinine 0.4, glucose 80, crp 0.5.  neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with dr. x, we did not see any infiltrate and cbg was normal.  ua and lp results are pending.  also pending are cultures for blood, lp, and urine.,assessment and plan: , this is a 3-week-old caucasian baby boy admitted for rule out sepsis and congenital heart disease.,infectious disease/pulmonary: , afebrile with so far 20-hour blood cultures, lp and urine cultures are negative.  we will get all the results from abcd and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  the patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,cvs: , he had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  these are the normal findings in a newborn as discussed with dr. y, so we will just observe the patient.  he does not need any further workup.,gastrointestinal: ",5
"subjective:,  the patient returns to the pulmonary medicine clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  she was last seen in the pulmonary medicine clinic in january 2004.  since that time, her respiratory status has been quite good.  she has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  she denies any problems with cough or sputum production.  no fevers or chills.  recently, she has had a bit more problems with fatigue.  for the most part, she has had no pulmonary limitations to her activity.,current medications:,  synthroid 0.112 mg daily; prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; plaquenil 200 mg b.i.d.; imuran 100 mg daily; advair one puff b.i.d.; premarin 0.3 mg daily; lipitor 10 mg monday through friday; actonel 35 mg weekly; and aspirin 81 mg daily.  she is also on calcium, vitamin d, vitamin e, vitamin c and a multivitamin.,allergies:,  penicillin and also intolerance to shellfish.,review of systems:,  noncontributory except as outlined above.,examination:,general:  the patient was in no acute distress.,vital signs:  blood pressure 122/60, pulse 72 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, but clear.,cardiovascular:  regular rate and rhythm.,abdomen:  soft and nontender.,extremities:  without edema.  no skin lesions.,o2 saturation was checked at rest.  on room air it was 96% and on ambulation it varied between 94% and 96%.  chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  she has not had the previous chest x-ray with which to compare; however, i did compare the markings was less prominent when compared with previous ct scan.,assessment:,1.  lupus with mild pneumonitis.,2.  respiratory status is stable.,3.  increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,plan:,  at this time, i have recommended to continue her current medications.  we would like to see her back in approximately four to five months, at which time i would like to recheck her pulmonary function test as well as check cat scan.  at that point, it may be reasonable to consider weaning her imuran if her pulmonary status is stable and the lupus appears to be under control.",3
"reason for visit: , acute kidney failure.,history of present illness: , the patient is a 68-year-old korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage iii ckd with a creatinine of 1.8 in may 2006 corresponding with the gfr of 40-41 ml/min.  the patient had blood work done at dr. xyz's office on june 01, 2006, which revealed an elevation in his creatinine up to 2.3.  he was asked to come in to see a nephrologist for further evaluation.  i am therefore asked by dr. xyz to see this patient in consultation for evaluation of acute on chronic kidney failure.  the patient states that he was actually taking up to 12 to 13 pills of chinese herbs and dietary supplements for the past year.  he only stopped about two or three weeks ago.  he also states that tricor was added about one or two months ago but he is not sure of the date.  he has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on flomax.  he states that his urinary dribbling and weak stream had not improved since doing this.  for the past couple of weeks, he has had dizziness in the morning.  this is then associated with low glucose.  however the patient's blood glucose this morning was 123 and he still was dizzy.  this was worse on standing.  he states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions.  his pulses remained in the 60s.,allergies: , none.,medications: , imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, zetia 10 mg daily, ? triglide 50 mg daily, prevacid 30 mg daily, plavix 75 mg daily, potassium 10 meq daily, lasix 60 mg daily, folate 1 mg b.i.d., niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., xanax 0.25 mg b.i.d., aspirin 325 mg daily, tylenol p.r.n., zantac 150 mg b.i.d., crestor 5 mg daily, tricor 145 mg daily, digitek 0.125 mg daily, celexa 20 mg daily, and flomax 0.4 mg daily.,past medical history:,1.  coronary artery disease status post cabg x 5 in december 2001.,2.  three stents last placed approximately 2002.,3.  heart failure, ejection fraction of 30%.,4.  hypertension since 1985.,5.  diabetes since 1985 with history of laser surgery.,6.  moderate mitral regurgitation.,7.  gi bleed.,8.  hyperlipidemia.,9.  bph.,10.  back surgery.,11.  sleep apnea.,social history: , he is a former tailor from korea.  he is divorced.  he has one daughter who has brain injury status post severe seizure as a child.  he is the primary caregiver.  no drug abuse.  he quit tobacco and alcohol 15 years ago.,family history: , parents both died in korea.  has one sister with hypertension and the other sister lives in detroit and is healthy.,review of systems: , he has lost about 10 pounds over the past month.  he has been fatigue and weak with no appetite.  he has occasional chest pain and dyspnea on exertion on fast walking.  his lower extremity edema has improved with higher doses of furosemide.  he does complain of some early satiety.  he complains of urinary frequency, nocturia, weak stream and dribbling.  he has never passed the stone.  he gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s.  he has some right back pain today and complains of farsightedness.  the remainder of review of systems is done and negative per the patient.,physical examination:,  vital signs:  pulse 78.  blood pressure 116/60.  height 5'7"" per the patient.  weight 78.6 kg.  supine pulse 60 with blood pressure 128/55.  standing pulse 60 with blood pressure of 132/50.  general:  he is in no apparent distress, but he is dizzy on standing for prolonged period.  eyes:  pupils equal, round and reactive to light.  extraocular movements are intact.  sclerae not icteric.  heent:  he wears upper and lower dentures.  lips acyanotic.  hearing is grossly intact.  oropharynx is otherwise clear.  neck:  supple.  no jvd.  no bruits.  no masses.  heart:  regular rate and rhythm.  no murmurs, rubs or gallops.  lungs:  clear bilaterally.  abdomen:  active bowel sounds.  soft, nontender, and nondistended.  no suprapubic tenderness.  extremities:  no clubbing, cyanosis or edema.  musculoskeletal:  5/5 strength bilaterally.  no synovitis, arthritis or gait disturbance.  skin:  old scars in his low back as well as his left lower extremity.  no active rashes, purpura or petechiae.  midline sternotomy scar is well healed.  neurologic:  cranial nerves ii through xii are intact.  reflexes are poor to 1+ bilaterally.  10 g monofilament sensation is intact except for the big toes bilaterally.  no asterixis.  finger-to-nose testing is intact.  psychiatric:  fully alert and oriented.,laboratory data:,  december 2004, creatinine was 1.5.  per report may 2006, creatinine was 1.8 with a bun of 28.  labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, co2 25, bun 46, creatinine 2.3, glucose 162, albumin 4.7, lfts are normal.  ck was elevated at 653.  a1c is 7.6%.  ldl cholesterol is 68, hdl is 35.  urinalysis reveals microalbumin to creatinine ratio 59.8.  ua was otherwise negative with a ph of 5.  today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dl of protein, ph of 5, negative nitrates, leukocyte esterase.  microscopic exam was bland.,impression:,1.  acute on chronic kidney failure.  he has underlying stage iii ckd with the gfr approximately 41 ml/min.  he has episodic hypotension at home and low diastolic pressure here.  his weight is down 2 to 3 kg from june and he may be prerenal.  he also has a history of prostatic hypertrophy and obstruction must be investigated.  i am also concerned about his use of chinese herbs which can cause chronic interstitial nephritis.  there is no evidence of pyuria today although this can present with a fairly bland sediment.  an additional concern is that tricor can cause an artifactual increase in the creatinine due to changes in metabolism.  i think this would be a diagnosis of exclusion.,2.  orthostatic hypotension.  he is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.,3.  elevated creatine kinase consistent with myositis.  it could be a result of crestor alone or combination of tricor and crestor.  i do not think this is enough to cause rhabdomyolysis, however.,recommendations:,1.  the patient was cautioned about using nsaids and told to avoid any further chinese herbs.,2.  recheck labs including cbc with differential, spep, uric acid and renal panel.,3.  decrease atenolol to 25 mg daily.,4.  decrease enalapril to 10 mg daily.,5.  decrease lasix to 20 mg daily.,6.  stop crestor.,7.  check renal ultrasound.,8.  see him back in two weeks for review of the studies.",20
"preoperative dx:,1.  menorrhagia,2.  desires permanent sterilization.,postoperative dx:,1.  menorrhagia,2.  desires permanent sterilization.,operative procedure:,  hysteroscopy, essure, tubal occlusion, and thermachoice endometrial ablation.,anesthesia: , general with paracervical block.,estimated blood loss: , minimal.,fluids:,  on hysteroscopy, 100 ml deficit of lactated ringer's via iv, 850 ml of lactated ringer's.,complications: , none.,pathology: , none.,disposition:  ,stable to recovery room.,findings:,  a nulliparous cervix without lesions.  uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,procedure: , the patient was taken to the operating room, where general anesthesia was found to be adequate.  she was prepped and draped in the usual sterile fashion.  a speculum was placed into the vagina.  the anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,the cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  the block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  the lidocaine was injected into the cervix.  the cervix was minimally dilated with #17 hanks dilator.  the 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated ringer's as a distention medium.  the uterine cavity was viewed and the above normal findings were noted.  the essure tubal occlusion was then inserted through the operative port and the tip of the essure device easily slid into the right ostia.  the coil was advanced and easily placed and the device withdrawn.  there were three coils into the uterine cavity after removal of the insertion device.  the device was removed and reloaded.  the advice was to advance under direct visualization and the tip was inserted into the left ostia.  this passed easily and the device was inserted.  it was removed easily and three coils again were into the uterine cavity.  the hysteroscope was then removed and the thermachoice ablation was performed.  the uterus was then sounded to 9.5 to 10 cm.  the thermachoice balloon was primed and pressure was drawn to a negative 150.  the device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of d5w.  the pressure was brought up to 170 and the cycle was initiated.  a full cycle of eight minutes was performed.  at no time there was a significant loss of pressure from the catheter balloon.  after the cycle was complete, the balloon was deflated and withdrawn.  the tenaculum was withdrawn.  no bleeding was noted.  the patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.",23
"preoperative diagnosis: , sebaceous cyst, right lateral eyebrow.,postoperative diagnosis:,  sebaceous cyst, right lateral eyebrow.,procedure performed: , excision of sebaceous cyst, right lateral eyebrow.,assistant: , none.,estimated blood loss: , minimal.,complications: , none.,anesthesia: , general endotracheal anesthesia.,condition of the patient at the end of the procedure: , stable.  transferred to the recovery room.,indications for procedure: , the patient is a 4-year-old with a history of sebaceous cyst.  the patient is undergoing pe tubes by dr. x and i was asked to remove the cyst on the right lateral eyebrow.  i saw the patient in my clinic.  i explained to the mother in spanish the risk and benefits.  risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery.  we will proceed with the surgery.,procedure in detail: , the patient was taken into the operating room, placed in the supine position.  general anesthetic was administered.  a prophylactic dose of antibiotic was given.  the patient was prepped and draped in a usual manner.  the procedure began by infiltrating lidocaine with epinephrine around the cyst area.  then, i proceeded with the help of a 15c blade to make an incision and remove a small wedge of tissue that includes a comedo point.  the incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst.  the cyst was detached of the surrounding structure with the help of blunt dissection.  hemostasis was achieved with electrocautery.  the wound was closed with 5-0 vicryl deep dermal interrupted stitches and dermabond.  the patient tolerated the procedure well without complications and transferred to recovery room in stable condition.  i was present and participated in all aspects of the procedure.  sponge, needle, and instrument counts were completed at the end of the procedure.",37
"preoperative diagnosis: , left distal ureteral stone.,postoperative diagnosis: , left distal ureteral stone.,procedure performed: , cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,anesthesia:,  lma.,ebl: , minimal.,fluids: , crystalloid.  the patient was given antibiotics, 1 g of ancef and the patient was on oral antibiotics at home.,brief history: , the patient is a 61-year-old female with history of recurrent uroseptic stones.  the patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  the patient understood and wanted to proceed with the procedure.,details of the procedure: , the patient was brought to the or.  anesthesia was applied.  the patient was placed in dorsal lithotomy position.  the patient was prepped and draped in usual sterile fashion.  a 0.035 glidewire was placed in the left system.  using graspers, left-sided stent was removed.  a semirigid ureteroscopy was done.  a stone was visualized in the mid to upper ureter.  using laser, the stone was broken into 5 to 6 small pieces.  using basket extraction, all the pieces were removed.  ureteroscopy all the way up to the upj was done, which was negative.  there were no further stones.  using pyelograms, the rest of the system appeared normal.  the entire ureter on the left side was open and patent.  there were no further stones.  due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  over the 0.035 glidewire, a 26 double-j stent was placed.  there was a nice curl in the kidney and one in the bladder.  the patient tolerated the procedure well.  please note that the string was kept in place and the patient was to remove the stent the next day.  the patient's family was instructed how to do so.  the patient had antibiotics and pain medications at home.  the patient was brought to recovery room in a stable condition.",20
"identifying data:,  this is a 40-year-old male seen today for a 90-day revocation admission.  he had been reported by his case manager as being noncompliant with medications, refusing oral or im medications, became agitated, had to be taken to abcd for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time.  he has a psychiatric history of schizophrenia, was previously admitted here at xyz on 12/19/2009, had another voluntary admission in abcd in 1998.,medications: , listed as invega and risperdal.,allergies: , none known to medications.,past medical history:  ,the only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil.  the patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,family history: , listed as unknown in the chart as far as other psychiatric illnesses.  the patient himself states that his parents are deceased and that he raised himself in the philippines.,social history:,  he immigrated to this country in 1984, although he lists himself as having a green card still at this time.  he states he lives on his own.  he is a single male with no history of marriage or children and that he had high school education.  his recreational drug use in the chart indicates that he has had a history of methamphetamines.  the patient denies this at this time.  he also denies current alcohol use.  he does smoke.  he is unable to tell me of any pcp.  he is in counseling service with his case manager being xyz.,legal history:  ,  he had an assault in december 2009, which led to his previous detention.  it is unknown whether he is under legal constraints at this time.,objective findings:  ,vital signs: , blood pressure is 125/75.  his weight is 197 with height 5 feet 4 inches.,general:,  he is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications.  he does not endorse any voices at this time.,heent: , his head exam is normal with normal scalp.  heent is unremarkable.  pupils equal and reactive to light and accommodation.  tms are normal.,neck:,  unremarkable with no masses or tenderness.,cardiovascular:,  normal s1 and s2.  no murmurs.,lungs:,  clear.,abdomen:  ,negative with no scars.,gu:  ,not done.,rectal:,  not done.,derm:,  he does have a scarring of acne lesions, both face and back.,extremities:,  otherwise negative.,neurologic: , cranial nerves ii through x normal.  reflexes are normal and gait is unremarkable.,laboratory data: , his labs done at abcd showed his cmp to be normal with an elevated white count of 17.2.  chest x-ray was indicated as being done and normal as was a ua and he did apparently receive hydration in the hospital with iv fluids.,assessment: , history of hyperlipidemia with elevated triglycerides.  we will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.",15
"preoperative diagnosis:,  acute cholecystitis.,postoperative diagnosis:,  acute gangrenous cholecystitis with cholelithiasis.,operation performed: , laparoscopic cholecystectomy with cholangiogram.,findings:  ,the patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,complications:  ,none.,ebl: , scant.,specimen removed: , gallbladder with stones.,description of procedure:  ,the patient was prepped and draped in the usual sterile fashion under general anesthesia.  a curvilinear incision was made below the umbilicus.  through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  once this complete, insufflation was begun.  once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  once all four ports were placed, the right upper quadrant was then explored.  the patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  this was taken down using bovie cautery to free up visualization of the gallbladder.  the gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  at this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  the cystic duct and cystic artery were serially clipped and transected.  the gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  adequate hemostasis with bovie cautery was achieved.  the gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  a jp drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  next, the right upper quadrant was copiously irrigated out using the suction irrigator.  once this was complete, the additional ports were able to be removed.  the fascial opening at the umbilicus was reinforced by closing it using a 0 vicryl suture in a figure-of-8 fashion.  all skin incisions were injected using marcaine 1/4 percent plain.  the skin was reapproximated further using 4-0 monocryl sutures in a subcuticular technique.  the patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.",37
"admission diagnoses:,1.  pyelonephritis.,2.  history of uterine cancer and ileal conduit urinary diversion.,3.  hypertension.,4.  renal insufficiency.,5.  anemia.,discharge diagnoses:,1.  pyelonephritis likely secondary to mucous plugging of indwelling foley in the ileal conduit.,2.  hypertension.,3.  mild renal insufficiency.,4.  anemia, which has been present chronically over the past year.,hospital course:,  the patient was admitted with suspected pyelonephritis.  renal was consulted.  it was thought that there was a thick mucous plug in the foley in the ileal conduit that was irrigated by dr. x.  her symptoms responded to iv antibiotics and she remained clinically stable.  klebsiella was isolated in this urine, which was sensitive to bactrim and she was discharged on p.o.  bactrim.  she was scheduled on 08/07/2007 for further surgery.  she is to follow up with dr. y in 7-10 days.  she also complained of right knee pain and the right knee showed no sign of effusion.  she was exquisitely tender to touch of the patellar tendon.  it was thought that this did not represent intraarticular process.  she was advised to use ibuprofen over-the-counter two to three tabs t.i.d.",10
"date of admission: , mm/dd/yyyy.,date of discharge: , mm/dd/yyyy.,admitting diagnosis:, peritoneal carcinomatosis from appendiceal primary.,discharge diagnosis:  , peritoneal carcinomatosis from appendiceal primary.,secondary diagnosis: , diarrhea.,attending physician: , ab cd, m.d.,service: , general surgery c, surgery oncology.,consulting services:,  urology.,procedures during this hospitalization:,  on mm/dd/yyyy, ,1.  cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2.  exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, iphc with mitomycin-c.,hospital course: , the patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on mm/dd/yyyy.  he was admitted to general surgery c service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement.  the patient was taken to the operative suite on mm/dd/yyyy and was first seen by urology for a cystoscopy with bilateral ureteral stent placement.  dr. xyz performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and iphc with mitomycin-c.  the procedure was without complications.  the patient was observed closely in the icu for one day postoperatively for persistent tachycardia after extubation.  he was then transferred to the floor where he has done exceptionally well.,on postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet.  we advanced him as tolerated to a regular health select diet by postoperative day #4.  his pain was well controlled throughout this hospitalization, initially with a pca pump, which he very seldomly used.  he was then switched over to p.o. pain medicines and has required very little for adequate pain control.  by postoperative date #2, the patient had been out of bed and ambulating in the hallways.  the patient's only problem was with some mild diarrhea on postoperative days #3 and 4.  this was thought to be a result of his right hemicolectomy.  a c. diff toxin was sent and came back negative and he was started on imodium to manage his diarrhea.  his post-splenectomy vaccines including pneumococcal, hib, and meningococcal vaccines were administered during his hospitalization.,on the day of discharge, the patient was resting comfortably in the bed without complaints.  he had been afebrile throughout his hospitalization and his vital signs were stable.  pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout.  his midline incision is clean, dry, and intact and staples are in place.  he is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,condition at discharge:  ,the patient was discharged in good and stable condition.,discharge medications:,1.  multivitamins daily.,2.  lovenox 40 mg in 0.4 ml solution inject subcutaneously once daily for 14 days.,3.  vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4.  phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5.  imodium a-d tablets take one tablet by mouth b.i.d. as needed for diarrhea.,discharge instructions:,  the patient was instructed to contact us with any questions or concerns that may arise.  in addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site.  he will be seen in about one week's time in dr. xyz's clinic and his staples will be removed at that time.,follow-up appointment: , the patient will be seen by dr. xyz in clinic in one week's time.",15
"chief complaint:,  the patient comes for her well-woman checkup.,history of present illness:,  she feels well.  she has had no real problems.  she has not had any vaginal bleeding.  she had a hysterectomy.  she has done fairly well from that time till now.  she feels like she is doing pretty well.  she remains sexually active occasionally.  she has not had any urinary symptoms.  no irregular vaginal bleeding.  she has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  she sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  she says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  she does not report any swelling or inflammation, or pain.  she had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,medications: , tetracycline 250 mg daily, inderal la 80 mg every other day.,allergies:,  sulfa.,past medical history:,  she had rosacea.  she also has problems with “tremors” and for that she takes inderal la.  hysterectomy in the past.,social history:,  she drinks four cups of coffee a day.  no soda.  no chocolate.  she said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  they walk every evening for one hour.,family history:,  her mother is in a nursing home; she had a stroke.  her father died at age 86 in january 2004 of congestive heart failure.  she has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,review of systems:,  patient denies headache or trauma.  no blurred or double vision.  hearing is fine, no tinnitus, or infection.  infrequent sore throat, no hoarseness, or cough.,neck:  no stiffness, pain, or swelling.,respiratory:  no shortness of breath, cough, or hemoptysis.,cardiovascular:  no chest pain, ankle edema, palpitations, or hypertension.,gi:  no nausea, vomiting, diarrhea, constipation, melena, or jaundice.,gu:  no dysuria, frequency, urgency, or stress incontinence.,locomotor:  no weakness, joint pain, tremor, or swelling.,gyn:  see hpi.,integumentary:  patient performs self-breast examinations and denies any breast masses or nipple discharge.  no recent skin or hair changes.,neuropsychiatric:  denies depression, anxiety, tearfulness, or suicidal thought.,physical examination:,vital signs:  height:  62 inches.  weight:  134 pounds.  blood pressure:  116/74.  pulse:  60.  respirations:  12.  age 59.,heent:  head is normocephalic.  eyes:  eoms intact.  perrla.  conjunctiva clear.  fundi:  discs flat, cups normal.  no av nicking, hemorrhage or exudate.  ears:  tms intact.  mouth:  no lesion.  throat:  no inflammation.  she fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  she wears glasses.,neck:  full range of motion.  no lymphadenopathy or thyromegaly.,chest:  clear to auscultation and percussion.,heart:  normal sinus rhythm, no murmur.,integumentary:  breasts are without masses, tenderness, nipple retraction, or discharge.  reviewed self-breast examination.  no axillary nodes are palpable.,abdomen:  soft.  liver, spleen, and kidneys are not palpable.  no masses felt, nontender.  femoral pulses strong and equal.,back:  no cva or spinal tenderness.  no deformity noted.,pelvic:  bus negative.  vaginal mucosa atrophic.  cervix and uterus are absent.  no pap was taken.  no adnexal masses.,rectal:  good sphincter tone.  no masses.  stool guaiac negative.,extremities:  no edema.  pulses strong and equal.  reflexes are intact.  romberg and babinski are negative.  she is oriented x 3.  gait is normal.,assessment:,  middle-aged woman, status post hysterectomy, recent urinary tract infection.,plan:,  we will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  i recommended mammogram and screening, hemoccult x 3, dexa scan and screening, and she is fasting today.  we will screen with chem-12, lipid profile, and cbc because of her advancing age and notify of those results, as soon as they are available.  continue same meds.  recheck annually unless she has problems sooner.",5
"indication: , iron deficiency anemia.,procedure:  ,colonoscopy with terminal ileum examination.,postoperative diagnosis:,  normal examination.,withdrawal time: , 15 minutes.,scope: , cf-h180al.,medications: , fentanyl 100 mcg and versed 10 mg.,procedure detail:  ,following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed.  questions were answered.  pause preprocedure was performed.,following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.  the ileocecal valve looked normal.  preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope.  the terminal ileum was intubated through the ileocecal valve for a 5 cm extent.  terminal ileum mucosa looked normal.,then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum.  no polyp, no diverticulum and no bleeding source was identified.,the patient was assessed upon completion of the procedure.  okay to discharge once criteria met.  ,recommendations:,  follow up with primary care physician.",37
"preoperative diagnosis: , screening. ,postoperative diagnosis:,  tiny polyps.,procedure performed:  , colonoscopy.,procedure:  , the procedure, indications, and risks were explained to the patient, who understood and agreed.  he was sedated with versed 3 mg, demerol 25 mg during the examination.  ,a digital rectal exam was performed and the pentax video colonoscope was advanced over the examiner's finger into the rectum.  it was passed to the level of the cecum.  the ileocecal valve was identified, as was the appendiceal orifice.  ,slowly withdrawal through the colon revealed a small polyp in the transverse colon.  this was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  in addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  this was also removed using the cold biopsy forceps.  further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,impression:  , tiny polyps.  ,plan:  , if adenomatous, repeat exam in five years.  otherwise, repeat exam in 10 years.,",37
"s -, an 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes.  she presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot.  she also has a left great toenail that is giving her problems as well.,o - ,plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter.  there is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter.  these lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening.  the first and fifth metatarsal heads are plantarflexed.  vibratory sensation appears to be absent.  dorsal pedal pulses are nonpalpable.  varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent.  the medial aspect of the left great toenail has dried blood under the nail.  the nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic.  all of the patient's toenails are elongated and discolored and opaque as well.  there is dried blood under the medial aspect of the left great toenail.,a - ,1.  painful feet.,",34
"procedure:, delayed primary chest closure.,indications: , the patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 norwood operation.  given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  he is now taken back to the operative room for delayed primary chest closure.,preop dx: , open chest status post modified stage 1 norwood operation.,postop dx:,  open chest status post modified stage 1 norwood operation.,anesthesia: , general endotracheal.,complications: , none.,findings:,  no evidence of intramediastinal purulence or hematoma.  he tolerated the procedure well.,details of procedure: , the patient was brought to the operating room and placed on the operating table in the supine position.  following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  the previously placed alloderm membrane was removed.  mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  both cavities were also irrigated and suctioned.  the drains were flushed and repositioned.  approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  the sternum was then smeared with a vancomycin paste.  the proximal aspect of the 5 mm rv-pa conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  the sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  the skin was closed with interrupted nylon sutures and a sterile dressing was placed.  the peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  the patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,i was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.",3
"chief complaint: , chest pain.,history of present illness:,  the patient is a 40-year-old white male who presents with a chief complaint of ""chest pain"".,the patient is diabetic and has a prior history of coronary artery disease.  the patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  the severity of the pain has progressively increased.  he describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  he ranks the pain a 7 on a scale of 1-10.  he admits some shortness of breath & diaphoresis.  he states that he has had nausea & 3 episodes of vomiting tonight.  he denies any fever or chills.  he admits prior episodes of similar pain prior to his ptca in 1995.  he states the pain is somewhat worse with walking and seems to be relieved with rest.  there is no change in pain with positioning.  he states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  the patient ranks his present pain a 4 on a scale of 1-10.  the most recent episode of pain has lasted one-hour.,the patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,review of systems:,  all other systems reviewed & are negative.,past medical history:,  diabetes mellitus type ii, hypertension, coronary artery disease, atrial fibrillation, status post ptca in 1995 by dr. abc.,social history: , denies alcohol or drugs.  smokes 2 packs of cigarettes per day.  works as a banker.,family history: , positive for coronary artery disease (father & brother).,medications: , aspirin 81 milligrams qday.  humulin n. insulin 50 units in a.m.  hctz 50 mg qday.  nitroglycerin 1/150 sublingually prn chest pain.,allergies: , penicillin.,physical exam: , the patient is a 40-year-old white male.,general:  the patient is moderately obese but he is otherwise well developed & well nourished.  he appears in moderate discomfort but there is no evidence of distress.  he is alert, and oriented to person place and circumstance.  there is no evidence of respiratory distress.  the patient ambulates",5
"her past medical history includes a presumed diagnosis of connective tissue disorder.  she has otherwise, good health.  she underwent a shoulder ligament repair for joint laxity.,she does not take any eye medications and she takes seasonale systemically.  she is allergic to penicillin.,the visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  over refraction on the right eye showed -0.50 sphere with acuity of 20/20 od.  she is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, os.  intraocular pressures are 13 ou and by applanation.  confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  gonioscopy showed normal anterior segment angle morphology in both eyes.  she does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,the lids were normal in both eyes.  conjunctivae were quite, ou.  cornea were clear in both eyes.  the anterior chamber is deep and quiet, ou.  she has clear lenses, which are in good position, ou.  dilated fundus exam shows moderately optically clear vitreous, ou.  the optic nerves are normal in size.  the cup-to-disc ratios were approximately 0.4, ou.  the nerve fiber layers are excellent, ou.  the macula, vessels, and periphery were normal in both eyes.  no evidence of peripheral retinal degeneration is present in either eye.,ms. abc has optically clear vitreous.  she does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,she does have moderate myopia, however.,this combination of findings suggests and is consistent with her systemic connective tissue disorder such as a stickler syndrome or a variant of stickler syndrome.,i discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  otherwise, i can see her in 1 to 2 years.",25
"subjective:,  the patient is a 75-year-old female who comes in today with concerns of having a stroke.  she states she feels like she has something in her throat.  she started with some dizziness this morning and some left hand and left jaw numbness.  she said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw dr. xyz for that who gave her some antivert.  she said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  she said she had an earache a day or so ago.  she has not had any cold symptoms.,allergies:,  demerol and codeine.,medications: , lotensin, lopid, metoprolol, and darvocet.,review of systems:,  the patient says that she feels little bit nauseated at times.  she denies chest pain or shortness of breath and again feels like she has something in her throat.  she has been able to swallow liquids okay.  she said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  she does say that she occasionally has numbness in her left hand prior to today.,physical examination:,general:  she is awake and alert, no acute distress.,vital signs:  blood pressure:  175/86.  temperature:  she is afebrile.  pulse:  78.  respiratory rate:  20.  o2 sat:  93% on room air.,heent:  her tms are normal bilaterally.  posterior pharynx is unremarkable.  it should be noted that her uvula did not deviate and neither did her tongue.  when she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,neck:  without adenopathy or thyromegaly.  carotids pulses are brisk without bruits.,lungs:  clear to auscultation.,heart:  regular rate and rhythm without murmur.,extremities:  her muscle strength is symmetrical and intact bilaterally.  dtrs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  she has a positive tinel’s sign on her left wrist.,neurological:  i also took monofilament and she could sense it easily when testing her sensation on her face.,assessment:,  bell’s palsy.,plan:,  we did get an ekg showed some st segment changes anterolaterally.  the only ekg i have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his ekg.  i assured her that it does not look like she has a stroke.  if she wants to prevent a stroke, obviously quitting her smoking would help.  it should be noted she also takes synthroid and zocor.  we are going to give her valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but i will not start her on steroids at this time, which she agreed with.",34
"myoview nuclear stress study,reason for the test:,  angina, coronary artery disease.,findings: , the patient exercised according to the lexiscan nuclear stress study, received a total of 0.4 mg of lexiscan.  at peak hyperemic effect, 25.8 mci of myoview injected for the stress imaging and earlier 8.1 mci of myoview injected for the resting and the usual spect and gated spect protocol was followed in the rest-stress sequence.,the data analyzed using cedars-sinai software.,the resting heart rate was 49 with the resting blood pressure of 149/86.  maximum heart rate achieved was 69 with a maximum blood pressure achieved of 172/76.,ekg at rest showed to be abnormal with sinus rhythm, left atrial enlargement, and inverted t-wave in 1, 2, and avl as well as from v4 to v6 with lvh.  maximal stress test ekg showed no change from baseline.,impression:  ,maximal lexiscan stress test with abnormal ekg at baseline maximal stress test, please refer to the myoview interpretation.,myoview interpretations,findings: , the left ventricle appears to be dilated on both stress and rest with no significant change between stress and rest with left ventricular end-diastolic volume of 227, end-systolic volume of 154 with moderately to severely reduced lv function with akinesis of the inferior and inferoseptal wall.  ef was calculated at 32%, estimated 35% to 40%.,cardiac perfusion reviewed, showed a large area of moderate-to-severe intensity in the inferior wall and small-to-medium area of severe intensity at the apex and inferoapical wall.  both defects showed no change on the resting indicative of a fixed defect in the inferior and inferoapical wall consistent with old inferior inferoapical mi.  no reversible defects indicative of myocardium at risk.  the lateral walls as well as the septum and most of the anterior wall showed no reversibility and near-normal perfusion.,impression:,1.  large fixed defect, inferior and apical wall, related to old myocardial infarction.,2.  no reversible ischemia identified.,3.  moderately reduced left ventricular function with ejection fraction of about 35% consistent with ischemic cardiomyopathy.",3
"preoperative diagnoses:,1.  neuromuscular dysphagia.,2.  protein-calorie malnutrition.,postoperative diagnoses:,1.  neuromuscular dysphagia.,2.  protein-calorie malnutrition.,procedures performed:,1.  esophagogastroduodenoscopy with photo.,2.  insertion of a percutaneous endoscopic gastrostomy tube.,anesthesia:,  iv sedation and local.,complications: , none.,disposition: , the patient tolerated the procedure well without difficulty.,brief history:  ,the patient is a 50-year-old african-american male who presented to abcd general hospital on 08/18/2003 secondary to right hemiparesis from a cva.  the patient deteriorated with several cvas and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  the patient also had neuromuscular dysfunction.  after extended period of time, per the patient's family request and requested by the icu staff, decision to place a feeding tube was decided and scheduled for today.,intraoperative findings: , the patient was found to have esophagitis as well as gastritis via egd and was placed on prevacid granules.,procedure: , after informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  first, the egd was to be performed.,the olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  esophagitis was noted.  the scope was then passed through the esophagus into the stomach.  the cardia, fundus, body, and antrum of the stomach were visualized.  there was evidence of gastritis.  the scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  next, attention was made to transilluminating the anterior abdominal wall for the peg placement.  the skin was then anesthetized with 1% lidocaine.  the finder needle was then inserted under direct visualization.  the catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  the ponsky peg tube was attached to the wire.  a skin nick was made with a #11 blade scalpel.  the wire was pulled back up through the abdominal wall point and ponsky peg back up through the abdominal wall and inserted into position.  the endoscope was then replaced confirming position.  photograph was taken.  the ponsky peg tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  we will begin tube feeds later this afternoon.",37
"preoperative diagnoses,1.  carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  left mandibular vestibular abscess.,postoperative diagnoses,1.  carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  left mandibular vestibular abscess.,procedure,1.  extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  incision and drainage (i&d) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,anesthesia:,  general nasotracheal.,complications: , none.,drain:,  quarter-inch penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,condition:,  the patient was taken to the pacu in stable condition.,indication:,  patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,description of procedure:,  patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  a gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 ml of lidocaine 2% with 1:100,000 epinephrine, and 3.6 ml of marcaine 0.5% with 1:200,000 epinephrine.  the area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 ml of purulent material was aspirated.  this was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  an incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  the area was bluntly dissected with a curved hemostat and a small amount of approximately 3 ml of purulent material was drained.  penrose drain was then placed using a curved hemostat.  the drain was secured with 3-0 silk suture.  the extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  after completion of the procedure, the throat pack was removed, the pharynx was suctioned.  the anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  the nasogastric tube was then removed.  patient was then extubated and taken to the pacu in stable condition.",7
"procedure: , newborn circumcision.,indications: , parental preference.,anesthesia:,  dorsal penile nerve block.,description of procedure:,  the baby was prepared and draped in a sterile manner.  lidocaine 1% 4 ml without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  the penile foreskin was removed using a xxx gomco.  hemostasis was achieved with minimal blood loss.  there was no sign of infection.  the baby tolerated the procedure well.  vaseline was applied to the penis, and the baby was diapered by nursing staff.",38
"constitutional:,  normal; negative for fever, weight change, fatigue, or aching.,heent:,  eyes normal; negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  ears normal; negative for hearing or balance problems.  nose normal; negative for runny nose, sinus problems, or nosebleeds.  mouth normal; negative for dental problems, dentures, or bleeding gums.  throat normal; negative for hoarseness, difficulty swallowing, or sore throat.,cardiovascular:,  normal; negative for angina, previous mi, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,pulmonary: , normal; negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,gastrointestinal: , normal; negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,genitourinary:, normal female or male; negative for incontinence, uti, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,skin: , normal; negative for rashes, keratoses, skin cancers, or acne.,musculoskeletal: , normal; negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,neurologic: , normal; negative for blackouts, headaches, seizures, stroke, or dizziness.,psychiatric: , normal; negative for anxiety, depression, or phobias.,endocrine:,  normal; negative for diabetes, thyroid, or problems with cholesterol or hormones.,hematologic/lymphatic: , normal; negative for anemia, swollen glands, or blood disorders.,immunologic: , negative; negative for steroids, chemotherapy, or cancer.,vascular:,  normal; negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.",5
"title of operation:,1.  austin-akin bunionectomy with internal screw fixation of the first right metatarsophalangeal joint.,2.  weil osteotomy with internal screw fixation, first right metatarsal.,3.  arthroplasty, second right pip joint.,preoperative diagnoses:,1.  bunion deformity, right foot.,2.  dislocated second right metatarsophalangeal joint.,3.  hammertoe deformity, second right digit.,postoperative diagnoses:,1.  bunion deformity, right foot.,2.  dislocated second right metatarsophalangeal joint.,3.  hammertoe deformity, second right digit.,anesthesia:,  monitored anesthesia care with 20 ml of 1:1 mixture of 0.5% marcaine and 1% lidocaine plain.,hemostasis:,  60 minutes, a right ankle tourniquet set at 250 mmhg.,estimated blood loss: , less than 10 ml.,preoperative injectables:  ,1 g ancef iv 30 minutes preoperatively.,materials used: , 3-0 vicryl, 4-0 vicryl, 5-0 prolene, as well as two 16-mm partially treaded cannulated screws of the osteomed system, one 18-mm partially treaded cannulated screw of the osteomed system of the 3.0 size.  one 10-mm 2.0 partially threaded cannulated screw of the osteomed system.,description of the procedure:  ,the patient was brought to the operating room and placed on the operating table in the supine position.  after adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical sites.  the right ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set up at 250 mmhg.  the right foot was then prepped, scrubbed, and draped in a normal sterile technique.  the right ankle tourniquet was then inflated.  attention was then directed on the dorsomedial aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed parallel and medial to the course of the extensor hallucis longus tendon to the right great toe.  the incision was deepened through subcutaneous tissues.  all the bleeders were identified, cut, clamped, and cauterized.  the incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  all the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  using sharp and dull dissection, the periosteal and capsular tissues were mobilized from the head and neck of the first right metatarsal and the base of the proximal phalanx of the right great toe.  the conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx and resected transversely.,a lateral capsulotomy was also performed at the level of the first right metatarsophalangeal joint.  using sharp and dull dissection, the dorsomedial prominence of the first right metatarsal head was adequately exposed and resected with the use of a sagittal saw.  the same saw was used to perform the austin osteotomy on the capital aspect of the first right metatarsal with its apex distal and its base proximal.  the dorsal arm of the osteotomy was longer than the plantar arm and noted to accommodate for the future internal fixation.  the capital fragment of the first right metatarsal was then transposed laterally and impacted on the shaft of the first right metatarsal.  two wires of the osteomed system were also used as provisional fixation wires and also as guidewires for the insertion of the future screws.  the wires were inserted dorsal distal to plantar proximal through the dorsal arm of the osteotomy.  the two screws from the 3.0 osteomed system were inserted over the wires using ao technique.  one screw measured 16 mm, second screw measured 18 mm in length.  both 3.0 screws were then evaluated for the fixation of the osteotomy after the wires were removed.  fixation of the osteotomy was found to be excellent.  the dorsomedial prominence of the first right metatarsal shaft was then resected with the sagittal saw.  to improve the correction of the hallux abductus angle, an akin osteotomy was also performed on the base of the proximal phalanx of the right great toe with its base medially and its apex laterally.  upon removal of the base wedge from the base of the proximal phalanx, the osteotomy was reduced with the osteomed smooth wire, which was also used as a guidewire for the insertion of a 16-mm partially threaded cannulated screw from the osteomed 3.0 system.  upon insertion of the screw, using ao technique, the wire was removed.  the screw was inserted proximal medial to distal lateral through the osteotomy of the base of the proximal phalanx of the right great toe.  fixation of the osteotomy was found to be excellent.  reduction of the bunion deformity was also found to be excellent and position of the first right metatarsophalangeal joint was found to be anatomical.  range of motion of that joint was uninhibited.  the area was flushed copiously with saline.  then, 3-0 suture material was used to approximate the periosteum and capsular tissues, 4-0 was used to approximate the subcutaneous tissues, and steri-strips were used to reinforce the incision.  attention was directed over the neck of the second right metatarsal head where a 3-cm linear incision was placed directly over the surgical neck of the second right metatarsal.  the incision was deepened through subcutaneous tissues.  all the bleeders were identified, cut, clamped and cauterized.  the incision was deepened through the level of the periosteum over the surgical neck of the second right metatarsal.  all the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  using sharp and dull dissection, the surgical neck of the second right metatarsal was adequately exposed and then weil-type osteotomy was performed from dorsal distal to plantar proximal through the surgical neck of the second right metatarsal.  the capital fragment was then transposed proximally and impacted on the shaft of the second right metatarsal.,the 2.0 osteo-med system was also used to fixate this osteotomy wire from that system was inserted dorsal proximal to plantar distal through the second right metatarsal osteotomy and the wire was used as a guidewire for the insertion of the 10-mm partially threaded 2.0 cannulated screw.  upon insertion of the screw, using ao technique, the wire was then removed.  fixation of the osteotomy with 2.0 screw was found to be excellent.  the second right metatarsophalangeal joint was then relocated and the dislocation of that joint was completely reduced.  range of motion of the second right metatarsophalangeal joint was found to be excellent.  then, 3-0 vicryl suture material was used to approximate the periosteal tissues.  then, 4-0 vicryl was used to approximate the skin incision.  attention was then directed at the level of the pip joint of the second right toe where two semi-elliptical incisions were placed directly over the bony prominence at the level of the second right pip joint.  the island of skin between the two semi-elliptical incisions was resected in toto.  the dissection was carried down to the level of extensor digitorum longus of the second right toe, which was resected transversely at the level of the pip joint.  a capsulotomy and a medial and lateral collateral ligament release of the pip joint of the second right toe was also performed and head of the proximal phalanx of the second right digit was adequately exposed.  using the double-action bone cutter, the head of the proximal phalanx of the second right toe was then resected.  the area was copiously flushed with saline.  the capsular and periosteal tissues were approximated with 2-0 vicryl and 3-0 vicryl suture material was also used to approximate the extensor digitorum longus to the second right toe.  a 5-0 prolene was used to approximate the skin edges of the two semi-elliptical incisions.  correction of the hammertoe deformity and relocation of the second right metatarsophalangeal joint were evaluated with the foot loaded and were found to be excellent and anatomical.  at this time, the patient's three incisions were covered with xeroform, copious amounts of fluff and kling, stockinette, and ace bandage.  the patient's right ankle tourniquet was deflated, time was 60 minutes.  immediate hyperemia was noted on the entire right lower extremity upon deflation of the cuffs.,the patient's right foot was placed in a surgical shoe and the patient was transferred to the recovery room under the care of anesthesia team with the vital signs stable and the vascular status at appropriate levels.  the patient was given instructions and education on how to continue caring for her right foot surgery.  the patient was eventually discharged from hospital according to nursing protocol and was advised to follow up with dr. x's office in one week's time for her first postoperative appointment.",26
"preoperative diagnosis:,  carcinoma of the left breast.,postoperative diagnosis:,  carcinoma of the left breast.,procedure performed: , true cut needle biopsy of the breast.,gross findings:  ,this 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  on exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  at this time, a true cut needle biopsy was performed.,procedure: , the patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  the area over the left breast was infiltrated with 1:1 mixture of 0.25% marcaine and 1% xylocaine.  using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  hemostasis was controlled with pressure.  the patient tolerated the procedure well, pending the results of biopsy.",37
"diagnosis at admission: , hypothermia.,diagnoses on discharge,1. hypothermia.,2. rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. organic brain syndrome.,4. seizure disorder.,5. adrenal insufficiency.,6. hypothyroidism.,7. anemia of chronic disease.,hospital course:  ,the patient was admitted through the emergency room.  he was admitted to the intensive care unit.  he was rewarmed and had blood, sputum, and urine cultures done.  he was placed on iv rocephin.  his usual medications of dilantin and depakene were given.  the patient's hypertension was treated with fluid boluses.  the patient was empirically placed on synthroid and hydrocortisone by dr. x.  blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  h&h was stable at 33.3/10.9 and platelets of 80,000.  white blood cell counts were normal, differential was normal.  tsh was 3.41.  free t4 was 0.9.  dr. x felt this was consistent with secondary hypothyroidism and recommended synthroid replacement.  a cortisol level was obtained prior to administration of hydrocortisone.  this was 10.9 and that was not a fasting level.  dr. x felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and florinef.  the patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his florinef 0.1 mg on monday, wednesday, and friday.  the patient was started back on his tube feeds.  he tolerated these poorly with residuals.  reglan was increased to 10 mg q.6 h. and erythromycin is being added.  the patient's temperature has been stable in the 94 to 95 range.  other vital signs have been stable.  his urine output has been diminished.  an external jugular line was placed in the intensive care unit.  the patient's legal guardian, janet sanchez in albuquerque has requested he be transported there.  as per several physicians in albuquerque and dr. y, an internist, we will accept him once we have a nursing home available to him.  he is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in albuquerque.  his prognosis is poor.",15
"preoperative diagnosis: , external iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,postoperative diagnosis:,  external iliac artery stenosis supplying recently transplanted kidney with renovascular hypertension and impaired renal function.,procedures:,1.  placement of right external iliac artery catheter via left femoral approach.,2.  arteriography of the right iliac arteries.,3.  primary open angioplasty of the right iliac artery using an 8 mm diameter x 3 cm length angioplasty balloon.,3.  open stent placement in the right external iliac artery for inadequate angiographic result of angioplasty alone.,anesthesia: , local with intravenous sedation.,indication for procedure:,  he is a 67-year-old white male who is well known to me.  he had severe peripheral vascular disease and recently underwent a kidney transplant.  he has had some troubles with increasing serum creatinine and hypertension.  duplex suggests a high-grade iliac stenosis just proximal to his transplant kidney.  he is brought to the operating room for arteriography and potential treatment of this.,description of procedure: , the patient was brought to operating room #14.  a condom catheter was put in place.  preoperative antibiotics were administered.  the patient's left arm was prepped and draped in the usual sterile fashion.  an incision was made over his brachial artery after anesthetizing the skin.  his brachial artery was dissected free and looped with vessel loops.  under direct vision, it was punctured with an 18-gauge needle and a short 3j guidewire and 6-french sheath put in place.  a 3j guidewire was then introduced after the administration of intravenous heparin and advanced into the descending thoracic aorta.  this was then advanced down into the right common iliac artery.  the catheter was placed over this and arteriography performed.  after adjusting the image intensifier to unfold the origin of the renal artery from the iliac system.  we were able to demonstrate an approximately 60-70% stenosis of the external iliac artery.  immediately preceding the origin of the artery for the transplant kidney, which appeared to be widely patent.  we elected to try and treat this.  with catheter support a magic torque guidewire was advanced through the stenosis and into the common femoral artery.  an 8 mm diameter x 3 cm length angioplasty balloon was positioned across the stenosis and inflated.  this inflation was held for one minute.  this was then deflated and a catheter positioned again in the proximal common iliac artery.  for this application, we used a guide catheter that would allow us to inject contrast without losing our wire purchase.  this showed an improvement in the stenosis, but a residual stenosis of at least 30% and we elected to stent this.  an 8 mm diameter x 3 cm length stent was chosen and placed just proximal to the origin of the renal artery.  after this was completed, the stent introduction balloon was removed and the catheter replaced.  repeat angiography showed a widely patent segment with no evidence of any residual stenosis.  there was no evidence of any dissection or damage to the renal artery.  we interpreted this as satisfactory procedure.  guidewires and sheaths were removed.  the brachial artery was repaired with two interrupted sutures of 7-0 prolene.  the wound was irrigated and the subcutaneous tissue closed with a running suture of vicryl.  the skin was reapproximated with a running intracuticular suture of monocryl.  steri-strips and sterile occlusive dressing were applied and the patient was taken to the recovery room in stable condition.  estimated blood loss for the procedure was less than 50 ml.  total contrast employed was 37.5 ml.  total fluoroscopy time was 12 minutes and 43 seconds.",37
"history: , the patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  she was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  this has required large amounts of opioid analgesics to control.  she has been basically bedridden because of this.  she was brought into hospital for further investigations.,physical examination: , on examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  difficult to assess individual muscles, but strength is largely intact.  sensory examination is symmetric.  deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  she has slightly decreased right versus left ankle reflexes.  the babinski's are positive.  on nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and f-waves are normal in lower extremities.,needle emg: , needle emg was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  it reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  there is evidence of denervation in right gastrocnemius medialis muscle.,impression: , this electrical study is abnormal.  it reveals the following:,1.  inactive right s1 (l5) radiculopathy.,2.  there is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,results were discussed with the patient and she is scheduled for imaging studies in the next day.",29
"past medical history: , her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke.  she denies any history of cancer.  she does have a history of hepatitis which i will need to further investigate.  she complains of multiple joint pains, and heavy snoring.,past surgical history: , includes hysterectomy in 1995 for fibroids and varicose vein removal.  she had one ovary removed at the time of the hysterectomy as well.,social history:,  she is a single mother of one adopted child.,family history:  ,there is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family.  her mother is alive.  her father is deceased from alcohol.  she has five siblings.,medications: , as you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, actos 15 mg, crestor 10 mg and cellcept 500 mg two times a day.,allergies: , she has no known drug allergies.,physical exam: , she is a 54-year-old obese female.  she does not appear to have any significant residual deficits from her stroke.  there may be slight left arm weakness.,assessment/plan:,  we will have her undergo routine nutritional and psychosocial assessment.  i suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss.  she is otherwise at increased risk for future complications given her history, and weight loss will be a good option.  we will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company.",5
"preoperative diagnosis:,  completely bony impacted teeth #1, #16, #17, and #32.,postoperative diagnosis: , completely bony impacted teeth #1, #16, #17, and #32.,procedure: , surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,anesthesia: , general nasotracheal.,complications: , none.,condition:  ,stable to pacu.,description of procedure: , patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  a gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 ml of lidocaine 2% with 1:100,000 epinephrine, and 3.6 ml of bupivacaine 0.5% with 1:200,000 epinephrine.  beginning on the upper right tooth #1, incision was made with a #15 blade.  envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  potts elevator was then used to luxate the tooth from the socket.  remnants of the follicle were then removed with hemostat.  the area was irrigated and then closed with 3-0 gut suture.  on the lower right tooth #32, incision was made with a #15 blade.  envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur.  tooth was then sectioned with the bur and removed in several pieces.  remnants of the follicle were removed with a curved hemostat.  the area was irrigated with normal saline solution and closed with 3-0 gut sutures.  moving to #16 on the upper left, incision was made with a #15 blade.  envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator.  potts elevator was then used to luxate the tooth from the socket.  remnants of the follicle were removed with a curved hemostat.  the area was irrigated with normal saline solution and closed with 3-0 gut sutures.  moving to the lower left #17, incision was made with a #15 blade.  envelope flap was  raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur.  then the bur was used to section the tooth vertically.  tooth was removed in several pieces followed by the removal of the remnants of the follicle.  the area was irrigated with normal saline solution and closed with 3-0 gut sutures.  upon completion of the procedure, the throat pack was removed and the pharynx was suctioned.  an ng tube was then inserted and small amount of gastric contents were suctioned.  patient was then awakened, extubated, and taken to the pacu in stable condition.",37
"preoperative diagnoses:,1.  nasal obstruction secondary to deviated nasal septum.,2.  bilateral turbinate hypertrophy.,procedure:,  cosmetic rhinoplasty.  request for cosmetic change in the external appearance of the nose.,anesthesia: , general via endotracheal tube.,indications for operation:  ,the patient is a 26-year-old white female with longstanding nasal obstruction.  she also has concerns with regard to the external appearance of her nose and is requesting changes in the external appearance of her nose.  from her functional standpoint, she has severe left-sided nasal septal deviation with compensatory inferior turbinate hypertrophy.  from the aesthetic standpoint, the nose is over projected, lacks rotation, and has a large dorsal hump.  first we are going to straighten the nasal septum and reduce the size of the turbinates and then we will also take down the hump, rotate the tip of the nose, and de-project the nasal tip.  i explained to her the risks, benefits, alternatives, and complications for postsurgical procedure.  she had her questions asked and answered and requested that we proceed with surgery as outlined above.,procedure details: , the patient was taken to the operating room and placed in supine position.  the appropriate level of general endotracheal anesthesia was induced.  the face, head, and neck were sterilely prepped and draped.  the nose was anesthetized and vasoconstricted in the usual fashion.  procedure began with a left hemitransfixion incision, which was brought down into the left intercartilaginous incision.  right intercartilaginous incision was also made and the dorsum of the nose was elevated in the submucoperichondrial and subperiosteal plane.  intact bilateral septomucoperichondrial flaps were elevated and a severe left-sided nasal septal deviation was corrected by detachment of the caudal nasal septum from the maxillary crest in a swinging door fashion and placing it back into the midline.  posterior vomerine spur was divided superiorly and inferiorly and a large spur was removed.  anterior and inferior one-third of each inferior turbinate was clamped, cut, and resected.  the upper lateral cartilages were divided from their attachments to the dorsal nasal septum and the cartilaginous septum was lowered by approximately 2 mm.  the bony hump of the nose was lowered with a straight osteotome by 4 mm.  fading medial osteotomies were carried out and lateral osteotomies were then created in order to narrow the bony width of the nose.  the tip of the nose was then addressed via a retrograde dissection and removal of cephalic caudal semicircle cartilage medially at the tip.  the caudal septum was shortened by 2 mm in an angle in order to enhance rotation.  medial crural footplates were reattached to the caudal nasal septum with a projection rotation control suture of #3-0 chromic.  the upper lateral cartilages were rejoined to the dorsal septum with a #4-0 plain gut suture.  no middle valves or bone grafts were necessary.  intact mucoperichondrial flaps were closed with 4-0 plain gut suture and doyle nasal splints were placed on either side of the nasal septum.  the middle meatus was filled with surgicel and cortisporin otic and external denver splint was applied with sterile tape and mastisol.  excellent aesthetic and functional results were thus obtained and the patient was awakened in the operating room, taken to the recovery room in good condition.",6
"preoperative diagnosis:,  medial meniscal tear, left knee.,postoperative diagnosis: , chondromalacia of medial femoral condyle.,procedure performed:,1.  arthroscopy of the left knee.,2.  left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  chondroplasty of the left knee as well.,estimated blood loss: , 80 cc.,total tourniquet time: , 19 minutes.,disposition: , the patient was taken to pacu in stable condition.,history of present illness:  ,the patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior mcl sprain.  he has had a positive symptomology of locking and pain since then.  he had no frank instability to it, however.,gross operative findings: , we did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,operative procedure:  ,the patient was taken to the operating room.  the left lower extremity was prepped and draped in the usual sterile fashion.  tourniquet was applied to the left thigh with adequate webril padding, not inflated at this time.  after the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmhg for a total of 19 minutes.  we established the lateral port of the knee with #11 blade scalpel.  we put in the arthroscopic trocar, instilled with water and inserted the camera.,on inspection of the patellofemoral joint, it was found to be quite smooth.  pictures were taken there.  there was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  the patella was well centered over the trochlear notch.  we then directed the arthroscope to the medial compartment of the knee.  it was felt that there was a tear to the medial meniscus.  we also saw large area of chondromalacia with grade-iv changes to bone over the medial femoral condyle.  this area was debrided with forceps and the arthroscopic shaver.  the cartilage was also smoothened over the medial femoral condyle.  this was curetted after the medial meniscus had been trimmed.  we looked into the notch.  we saw the acl appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  all instruments were removed.  all loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  we removed all instruments.  marcaine was injected into the portal sites.  we placed a sterile dressing and stockinet on the left lower extremity.  he was transferred to the gurney and taken to pacu in stable condition.",37
"preoperative diagnosis:,  vitreous hemorrhage, right eye.,postoperative diagnosis: , vitreous hemorrhage, right eye.,procedure:  ,vitrectomy, right eye.,procedure in detail:  ,the patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  initially, a 5 cc retrobulbar injection was performed with 2% xylocaine during monitored anesthesia control.  a lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  mvr incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 vicryl suture.  then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  all strands of significance were removed.  tractional detachment foci were apparent posteriorly along the temporal arcades.  next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  the intraocular pressure was within the normal range.  the globe was irrigated with a topical antibiotic.  the mvr incisions were closed with 7-0 vicryl.  no further manipulations were necessary.  the conjunctiva was closed with 6-0 plain catgut.  an eye patch was applied and the patient was sent to the recovery area in good condition.",37
"please accept this letter of follow up on patient xxx xxx. he is now three months out from a left carotid angioplasty and stent placement. he was a part of a capsure trial. he has done quite well, with no neurologic or cardiac event in the three months of follow up. he had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,sincerely,,xyz, md,",19
"history of present illness: , this is the case of a 31-year-old white female admitted to the hospital with pelvic pain and vaginal bleeding.  the patient had a positive hcg with a negative sonogram and hcg titer of about 18,000.,hospital course:,  the patient was admitted to the hospital with the diagnosis of a possible incomplete abortion, to rule out ectopic pregnancy or rupture of corpus luteal cyst.  the patient was kept in observation for 24 hours.  the sonogram stated there was no gestational sac, but there was a small mass within the uterus that could represent a gestational sac.  the patient was admitted to the hospital.  a repeat hcg titer done on the same day came back as 15,000, but then the following day, it came back as 18,000.  the diagnosis of a possible ruptured ectopic pregnancy was established.  the patient was taken to surgery and a laparotomy was performed with findings of a right ruptured ectopic pregnancy.  the right salpingectomy was performed with no complications.  the patient received 2 units of red packed cells.  on admission, her hemoglobin was 12.9, then in the afternoon it dropped to 8.1, and the following morning, it was 7.9.  again, based on these findings, the severe abdominal pain, we made the diagnosis of ectopic and it was proved or confirmed at surgery.  the hospital course was uneventful.  there was no fever reported.  the abdomen was soft.  she had a normal bowel movement.  the patient was dismissed on 09/09/2007 to be followed in my office in 4 days.,final diagnoses:,1.  right ruptured ectopic pregnancy with hemoperitoneum.,2.  anemia secondary to blood loss.,plan: , the patient will be dismissed on pain medication and iron therapy.",23
"admitting diagnosis:,  abscess with cellulitis, left foot.,discharge diagnosis:,  status post i&d, left foot.,procedures:,  incision and drainage, first metatarsal head, left foot with culture and sensitivity.,history of present illness:,  the patient presented to dr. x's office on 06/14/07 complaining of a painful left foot.  the patient had been treated conservatively in office for approximately 5 days, but symptoms progressed with the need of incision and drainage being decided.,medications:,  ancef iv.,allergies:,  accutane.,social history:,  denies smoking or drinking.,physical examination: , palpable pedal pulses noted bilaterally.  capillary refill time less than 3 seconds, digits 1 through 5 bilateral.  skin supple and intact with positive hair growth.  epicritic sensation intact bilateral.  muscle strength +5/5, dorsiflexors, plantar flexors, invertors, evertors.  left foot with erythema, edema, positive tenderness noted, left forefoot area.,laboratory: , white blood cell count never was abnormal.  the remaining within normal limits.  x-ray is negative for osteomyelitis.  on 06/14/07, the patient was taken to the or for incision and drainage of left foot abscess.  the patient tolerated the procedure well and was admitted and placed on vancomycin 1 g q.12h after surgery and later changed ancef 2 g iv every 8 hours.  postop wound care consists of aquacel ag and dry dressing to the surgical site everyday and the patient remains nonweightbearing on the left foot.  the patient progressively improved with iv antibiotics and local wound care and was discharged from the hospital on 06/19/07 in excellent condition.,discharge medications: , lorcet 10/650 mg, dispense 24 tablets, one tablet to be taken by mouth q.6h as needed for pain.  the patient was continued on ancef 2 g iv via picc line and home health administration of iv antibiotics.,discharge instructions: , included keeping the foot elevated with long periods of rest.  the patient is to wear surgical shoe at all times for ambulation and to avoid excessive ambulation.  the patient to keep dressing dry and intact, left foot.  the patient to contact dr. x for all followup care, if any problems arise.  the patient was given written and oral instruction about wound care before discharge.  prior to discharge, the patient was noted to be afebrile.  all vitals were stable.  the patient's questions were answered and the patient was discharged in apparent satisfactory condition.  followup care was given via dr. x' office.",10
"indications for procedure:, this is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. cpk is already over 1000. there is st elevation in leads ii and avf, as well as a q wave. the chest pain is now gone, mild residual shortness of breath, no orthopnea. cardiac monitor shows resolution of st elevation lead iii.,description of procedure:, following sterile prep and drape of the right groin, installation of 1% xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-french sheath inserted. act approximately 165 seconds on heparin. borderline hypotension 250 ml fluid bolus given and nitroglycerin patch removed. selective left and right coronary injections performed using judkins coronary catheters with a 6-french pigtail catheter used to obtain left ventricular pressures and left ventriculography. left pullback pressure. sheath injection. hemostasis obtained with a 6-french angio-seal device. he tolerated the procedure well and was transported to the cardiac step-down unit in stable condition.,hemodynamic data:, left ventricular end diastolic pressure elevated post a-wave at 25 mm of mercury with no aortic valve systolic gradient on pullback.,angiographic findings:,i. left coronary artery: the left main coronary artery is unremarkable. the left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. the first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. the second diagonal branch is unremarkable, as are the tiny distal diagonal branches. the intermediate branch is a small, normal vessel. the ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small av sulcus circumflex branch.,ii. right coronary artery: the right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. there are luminal irregularities, less than 25%, within the proximal to mid vessel. some contrast thinning is present in the distal rca just before the bifurcation into posterior descending and posterolateral branches. a 25%, smooth narrowing at the origin of the posterior descending branch. posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,iii. left ventriculogram: the left ventricle is normal in size. ejection fraction estimated at 40 to 45%. no mitral regurgitation. severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,discussion:, recent inferior myocardial infarction with only minor contrast thinning distal rca remaining on coronary angiography with resolution of chest pain and st segment elevation. left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,plan:, medical treatment, including plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.",37
"preoperative diagnosis: , left neck abscess.,postoperative diagnosis: , left neck abscess.,operative procedure: , incision and drainage of left neck abscess.,anesthesia:  ,general inhalational.,description of procedure: , the patient was taken to operating room and placed supine on the operating table.  general inhalational anesthesia was administered.  the patient was draped in usual fashion.  the prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 ml of local anesthetic using 1% xylocaine with epinephrine 1:100,000.  the incision was performed with a #15 blade.  an 18-gauge needle and 10 ml syringe was used to evacuate a small amount of the purulence from the abscess cavity.  this was submitted for culture and sensitivity, anaerobic cultures and gram stain.  the cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated.  the cavity was irrigated with peroxide and saline.  a 0.25-inch penrose drain was placed and secured with a single #3-0 nylon suture.  a 4 x 4 dressing was applied.  bleeding was negligible.  there were no untoward complications.  the patient tolerated the procedure well and was transferred to the recovery room in stable condition.",37
"subjective:,  the patient is keeping a food journal that she brought in.  she is counting calorie points, which ranged 26 to 30 per day.  she is exercising pretty regularly.  she attends overeaters anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  the patient requests information on diabetic exchanges.  she said she is feeling better since she has lost weight.,objective:,vital signs:  the patient's weight today is 209 pounds, which is down 22 pounds since i last saw her on 06/07/2004.  i praised her weight loss and her regular exercising.  i looked at her food journal.  i praised her record keeping.  i gave her a list of the diabetic exchanges and explained them.  i also gave her a food dairy sheet so that she could record exchanges.  i encouraged her to continue.,assessment:,  the patient seems happy with her progress and she seems to be doing well.  she needs to continue.,plan:,  followup is on a p.r.n. basis.  she is always welcome to call or return.",5
"preoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy.,2.  residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 with probable instability.,postoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy.,2.  residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 secondary to facet arthropathy with scar tissue.,3.  no evidence of instability.,operative procedure performed,1.  bilateral c3-c4, c4-c5, c5-c6, and c6-c7 medial facetectomy and foraminotomy with technical difficulty.,2.  total laminectomy c3, c4, c5, and c6.,3.  excision of scar tissue.,4.  repair of dural tear with prolene 6-0 and tisseel.,fluids:,  1500 cc of crystalloid.,urine output: , 200 cc.,drains: , none.,specimens: , none.,complications: , none.,anesthesia:,  general endotracheal anesthesia.,estimated blood loss:,  less than 250 cc.,indications for the operation:  ,this is the case of a very pleasant 41 year-old caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  last surgery consisted of four-level decompression on 08/28/06.  the patient continued to complain of posterior neck pain radiating to both trapezius.  review of his mri revealed the presence of what still appeared to be residual lateral recess stenosis.  it also raised the possibility of instability and based on this i recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  based on this, i did total decompression by removing the lamina of c3 through c6 and doing bilateral medial facetectomy and foraminotomy at c3-c4, c4-c5, c5-c6, and c6-c7 with no spinal instrumentation.  operation and expected outcome risks and benefits were discussed with him prior to the surgery.  risks include but not exclusive of bleeding and infection.  infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  there is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  this may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  there is also the risk of a dural tear with its attendant problems of csf leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  this too may require return to the operating room for evacuation of said pseudomeningocele and repair.  the patient understood the risk of the surgery.  i told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,description of procedure: , the patient was brought to the operating room, awake, alert, not in any form of distress.  after smooth induction and intubation, a foley catheter was inserted.  monitoring leads were also placed by premier neurodiagnostics for both ssep and emg monitoring.  the sseps were normal, and the emgs were silent during the entire case.  after completion of the placement of the monitoring leads, the patient was then positioned prone on a wilson frame with the head supported on a foam facial support.  shave was then carried out over the occipital and suboccipital region.  all pressure points were padded.  i proceeded to mark the hypertrophic scar for excision.  this was initially cleaned with alcohol and prepped with duraprep.,after sterile drapes were laid out, incision was made using a scalpel blade #10.  wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of c2 was then identified.  there was absence of the spinous process of c3, c4, c5, and c6, but partial laminectomy was noted; removal of only 15% of the lamina.  with this completed, we proceeded to do a total laminectomy at c3, c4, c5, and c6, which was technically difficult due to the previous surgery.  there was also a dural tear on the right c3-c4 space that was exposed and repaired with prolene 6-0 and later with tisseel.  by careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at c3-c4, c4-c5, c5-c6, and c6-c7.  there was significant epidural bleeding, which was carefully coagulated.  at two points, i had to pack this with small pieces of gelfoam.  after repair of the dural tear, valsalva maneuver showed no evidence of any csf leakage.  area was irrigated with saline and bacitracin and then lined with tisseel.  the wound was then closed in layers with vicryl 0 simple interrupted sutures to the fascia; vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  the patient was extubated and transferred to recovery.",22
"cc:, progressive unsteadiness following head trauma.,hx:,  a7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. he then began to experience progressive unsteadiness and gait instability for several days after the fall. he was then evaluated at a local er and prescribed meclizine. this did not improve his symptoms, and over the past one week prior to admission began to develop left facial/lue/lle weakness. he was seen by a local md on the 12/8/92 and underwent and mri brain scan. this showed a right subdural mass. he was then transferred to uihc for further evaluation.,pmh:, 1)cardiac arrhythmia. 2)htn. 3) excision of lip lesion 1 yr ago.,shx/fhx:, unremarkable. no h/o etoh abuse.,meds:, meclizine, procardia xl.,exam:, afebrile, bp132/74 hr72 rr16,ms: a & o x 3. speech fluent. comprehension, naming, repetition were intact.,cn: left lower facial weakness only.,motor: left hemiparesis, 4+/5 throughout.,sensory: intact pp/temp/lt/prop/vib,coordination: nd,station: left pronator drift.,gait: left hemiparesis evident by decreased lue swing and lle drag.,reflexes: 2/3 in ue; 2/2 le; right plantar downgoing; left plantar equivocal.,gen exam: unremarkable.,course:, outside mri revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. there was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,he underwent a hct on admission, 12/8/92, which showed a right subdural hematoma. he then underwent emergent evacuation of this hematoma. he was discharged home 6 days after surgery.",32
"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.",14
"history of present illness:,  the patient is well known to me for a history of iron-deficiency anemia due to chronic blood loss from colitis.  we corrected her hematocrit last year with intravenous (iv) iron.  ultimately, she had a total proctocolectomy done on 03/14/2007 to treat her colitis.  her course has been very complicated since then with needing multiple surgeries for removal of hematoma.  this is partly because she was on anticoagulation for a right arm deep venous thrombosis (dvt) she had early this year, complicated by septic phlebitis.,chart was reviewed, and i will not reiterate her complex history.,i am asked to see the patient again because of concerns for coagulopathy.,she had surgery again last month to evacuate a pelvic hematoma, and was found to have vancomycin resistant enterococcus, for which she is on multiple antibiotics and followed by infectious disease now.,she is on total parenteral nutrition (tpn) as well.,laboratory data:,  labs today showed a white blood count of 7.9, hemoglobin 11.0, hematocrit 32.8, and platelets 1,121,000.  mcv is 89.  her platelets have been elevated for at least the past week, with counts initially at the 600,000 to 700,000 range and in the last couple of day rising above 1,000,000.  her hematocrit has been essentially stable for the past month or so.  white blood count has improved.,pt has been markedly elevated and today is 44.9 with an inr of 5.0.  this is despite stopping coumadin on 05/31/2007, and with administration of vitamin k via the tpn, as well as additional doses iv.  the pt is slightly improved over the last few days, being high at 65.0 with an inr of 7.3 yesterday.,ptt has not been checked since 05/18/2007 and was normal then at 28.,lfts have been elevated.  alt is 100, ast 57, ggt 226, alkaline phosphatase 505, albumin low at 3.3, uric acid high at 4.9, bilirubin normal, ldh normal, and pre-albumin low at 16.  creatinine is at 1.5, with an estimated creatinine clearance low at 41.7.  other electrolytes are fairly normal.,b12 was assessed on 05/19/2007 and was normal at 941.  folic acid was normal.  iron saturation has not been checked since march, and was normal then.  ferritin has not been checked in a couple of months.,current medications: , erythropoietin 45,000 units every week, started 05/16/2007.  she is on heparin flushes, loperamide, niacin, pantoprazole, diovan, afrin nasal spray, caspofungin, daptomycin, ertapenem, fentanyl or morphine p.r.n. pain, and compazine or zofran p.r.n. nausea.,physical examination: ,general:  she is alert, and frustrated with her prolonged hospital stay.  she notes that she had epistaxis a few days ago, requiring nasal packing and fortunately that had resolved now.,vital signs:  today, temperature is 98.5, pulse 99, respirations 16, blood pressure 105/65, and pulse is 95.  she is not requiring oxygen.,skin:  no significant ecchymoses are noted.,abdomen:  ileostomy is in place, with greenish black liquid output.  midline surgical scar has healed well, with a dressing in place in the middle, with no bleeding noted.,extremities:  she has no peripheral edema.,cardiac:  regular rate.,lymphatics:  no adenopathy is noted.,lungs:  clear bilaterally.,impression and plan:,  markedly elevated pt/inr despite stopping coumadin and administering vitamin k.  i will check mixing studies to see if she has deficiency, which could be due to poor production given her elevated lfts, decreased albumin, and decreased pre-albumin.,it is possible that she has an inhibitor, which would have to be an acquired inhibitor, generally presenting with an elevated ptt and not pt.  i will check a ptt and check mixing studies if that is prolonged.  it is doubtful that she has a lupus anticoagulant since she has been presenting with bleeding symptoms rather than clotting.  i agree with continuing off of anticoagulation for now.,she has markedly elevated platelet count.  i suspect this is likely reactive to infection, and not from a new myeloproliferative disorder.,anemia has been stable, and is multifactorial.  given her decreased creatinine clearance, i agree with erythropoietin support.  she was iron deficient last year, and with her multiple surgeries and poor p.o. intake, may have become iron deficient again.  she has had part of her small bowel removed, so there may be a component of poor absorption as well.  if she is iron deficient, this may contribute also to her elevated platelet counts.  i will check a ferritin.  this may be difficult to interpret because of inflammation.  if it is decreased, plan will be to add iron supplementation intravenously.  if it is elevated, we could consider a bone marrow biopsy to evaluate her iron stores, and also assess her myelopoiesis given the markedly elevated platelet counts.,she needs continued treatment as you are for her infections.,i will discuss the case with dr. x as well since there is a question as to whether she might need additional surgery.  she is not a surgical candidate now with her elevated pt/inr.",5
"subjective:,  this 45-year-old gravida 3, para 2, sab 1 white female presents for exam and pap.  last pap was a year ago and normal.  lmp was 08/29/2004.  her cycles are usually regular, although that one came about a week early.  her husband has had a vasectomy.  overall, she is feeling well.,health history form was reviewed.  there has been no change in her personal history.  she notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  social history is unchanged.,health habits: , she states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  right now, she is not doing nearly as well.  she has perhaps two dairy servings daily, trying to cut down.  she is not exercising at all and fruit and vegetable intake varies.  she is a nonsmoker.  last cholesterol was in 2003 and was normal.  she had a mammogram which was normal recently.  she is current on her tetanus update.,review of systems:,heent:  she feels as though she may have some allergies at night.  most of her symptoms occur then, not during the day.  she will wake up with some congestion, sneezing, and then rhinorrhea.  currently, she uses tylenol sinus.  today, her symptoms are much better.  we did have rain this morning.,respiratory and cv:  negative.,gi:  she tends to have a little gas which is worse when she is eating more fruits and vegetables.  she had been somewhat constipated but that is better.,gu:  negative.,dermatologic:  she noticed an area of irritation on her right third finger on the ulnar side at the pip joint.  it was very sensitive to water.  it seems to be slowly improving.,objective:,vital signs:  her weight was 154 pounds, which is down 2 pounds.  blood pressure 104/66.,general:  she is a well-developed, well-nourished, pleasant white female in no distress.,neck:  supple without adenopathy.  no thyromegaly or nodules palpable.,lungs:  clear to a&p.,heart:  regular rate and rhythm without murmurs.,breasts:  symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,abdomen:  soft without organomegaly, masses, or tenderness.,pelvic:  reveals no external lesions.  the cervix is parous.  pap smear done.  uterus is anteverted and normal in size, shape, and consistency, and nontender.  no adnexal enlargement.,extremities:  examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,assessment:,1.  normal gyn exam.,2.  rhinitis, primarily in the mornings.  vasomotor versus allergic.,3.  eczematous dermatitis on right third finger.,plan:,1.  discussed vasomotor rhinitis.  i suggested she try ayr nasal saline gel.  another option would be a steroid spray and a sample of nasonex is given to use two sprays in each nostril daily.,2.  exam with pap annually.,3.  hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  discussed nutrition and exercise.  i recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.",5
"preoperative diagnosis: , right breast mass with atypical proliferative cells on fine-needle aspiration.,postoperative diagnosis:,  benign breast mass.,anesthesia: , general,name of operation:,  excision of right breast mass.,procedure:,  with the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  a curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  hemostasis was obtained using electrocautery.  frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  the breast tissues were approximated using 4-0 vicryl.  the skin was closed using 5-0 vicryl running subcuticular stitches.  a sterile bandage was applied.  the patient tolerated the procedure well.,",16
"preoperative diagnoses,1.  dyspnea on exertion with abnormal stress echocardiography.,2.  frequent pvcs.,3.  metabolic syndrome.,postoperative diagnoses,1.  a 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  frequent pvcs.,3.  metabolic syndrome.,procedures,1.  left heart catheterization with left ventriculography.,2.  selective coronary angiography.,complications: , none.,description of procedure: , after informed consent was obtained, the patient was brought to the cardiac catheterization laboratory in fasting state.  both groins were prepped and draped in the usual sterile fashion.  xylocaine 1% was used as local anesthetic.  versed and fentanyl were used for conscious sedation.  next, a #6-french sheath was placed in the right femoral artery using modified seldinger technique.  next, selective angiography of the left coronary artery was performed in multiple views using #6-french jl4 catheter.  next, selective angiography of the right coronary artery was performed in multiple views using #6-french 3drc catheter.  next, a #6-french angle pigtail catheter was advanced into the left ventricle.  the left ventricular pressure was then recorded.  left ventriculography was the performed using 36 ml of contrast injected over 3 seconds.  the left heart pull back was then performed.  the catheter was then removed.,angiography of the right femoral artery was performed.  hemostasis was obtained by angio-seal closure device.  the patient left the cardiac catheterization laboratory in stable condition.,hemodynamics,1.  lv pressure was 163/0 with end-diastolic pressure of 17.  there was no significant gradient across the aortic valve.,2.  left ventriculography showed old inferior wall hypokinesis.  global left ventricular systolic function is normal.  estimated ejection fraction was 58%.  there is no significant mitral regurgitation.,3.  significant coronary artery disease.,4.  the left main is approximately 7 or 8 mm proximally.  it trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  the distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  the left anterior descending artery is around 4 mm proximally.  it extends slightly beyond the apex into the inferior wall.  it gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  at the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow lao with caudal angulation.,there was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,the ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  there was no significant disease noted in the ramus intermedius artery however.,the left circumflex artery is around 2.5 mm proximally.  it gave off a recurrent atrial branch and a small av groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  the mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,the right coronary artery is around 4 mm in diameter.  it gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  in the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  the posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,plan:  ,plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  continue risk factor modification, aspirin, and beta blocker.",37
"reason for visit:  ,the patient is a 76-year-old man referred for neurological consultation by dr. x.  the patient is companied to clinic today by his wife and daughter.  he provides a small portion of his history; however, his family provides virtually all of it.,history of present illness: , he has trouble with walking and balance, with bladder control, and with thinking and memory.  when i asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  he is vaguely aware that he has trouble with his memory.,according to his family, he has had difficulty with his gait for at least three or four years.  at first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  they did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  as time progressed, he developed more and more difficulty.  he started to shuffle.  he started using a cane about two and a half years ago and has used a walker with wheels in the front since july of 2006.  at this point, he frequently if not always has trouble getting in or out of the seat.  he frequently tends to lean backwards or sideways when sitting.  he frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  he has not fallen in the last month.  he did fall earlier, but there seemed to be fewer opportunities for him to fall.  his family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  he has no stairs in his home, however, his family indicates that he would not be able to take stairs.  his handwriting has become smaller and shakier.,in regard to the bladder, he states, ""i wet the bed.""  in talking with his family, it seems as if he has no warning that he needs to empty his bladder.  he was diagnosed with a small bladder tumor in 2005.  this was treated by dr. y.  dr. x does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  the patient has worn a pad or undergarment for at least one to one and a half years.  his wife states that they go through two or three of them per day.  he has been placed on medications; however, they have not helped.,he has no headaches or sensation of head fullness.,in regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  now he seems less spontaneous and his family states he seems to have trouble expressing himself.  his wife took over his medications about two years ago.  she stopped his driving about three years ago.  she discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  apparently, he did not object.  at this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  he needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  he is a retired office machine repairman.  he is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,he has not had pt or ot and has not been treated with medications for parkinson's disease or alzheimer's disease.  he has been treated for the bladder.  he has not had lumbar puncture.,past medical history and review of all 14 systems from the form they completed for this visit that i reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  the bladder tumor was discovered in 2005 and was treated noninvasively.  he has lost weight from about 200 pounds to 180 pounds over the last two or three years.  he had a period of depression in 1999 and was on prozac for a while, but this was then stopped.  he used to drink a significant amount of alcohol.  this was problematic enough that his wife was concerned.  she states he stopped when she retired and she was at home all day.,social history:  ,he quit smoking in 1968.  his current weight is 183 pounds.  his tallest height is 5 feet 10 inches.,family history:  ,his grandfather had arthritis.  his father had parkinson's disease.  his mother had heart disease and a sister has diabetes.,he does not have a living will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,review of hydrocephalus risk factors: , none.,allergies: , none.,medications: , metformin 500 mg three times a day, lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, uroxatral 10 mg per day, detrol la 4 mg per day, and aspirin 81 mg per day.,physical exam: , on examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  he is well developed, well nourished, and kempt.,vital signs:  his weight is 180 pounds.,head:  the head is normocephalic and atraumatic.  the head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,spine:  the spine is straight and not tender.  i can easily palpate the spinous processes.  there is no scoliosis.,skin:  no neurocutaneous stigmata.,cardiovascular examination:  no carotid or vertebral bruits.,mental status:  assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  the mini-mental state exam score was 17/30.  he did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  there was a tendency for perseveration during the evaluation.  he could not copy the diagram of intersecting pentagons.,cranial nerve exam:  no evidence of papilledema.  the pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,motor exam:  normal bulk and strength, but the tone is marked by significant paratonia.  there is no atrophy, fasciculations, or drift.  there is tremulousness of the outstretched hands.,sensory exam:  is difficult to interpret.  either he does not understand the test or he is mostly guessing.,cerebellar exam:  is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  there is no dysarthria.,reflexes:  trace in the arms, 2+ at the knees, and 0 at the ankles.  it is not certain whether there is a babinski sign or simply withdrawal.,gait:  assessed using the tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,review of x-rays: , i personally reviewed the mri scan of the brain from december 11, 2007 at advanced radiology.  it shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  the 3rd ventricle contour is flat.  the span is enlarged at 12 mm.  the sylvian aqueduct is patent.  there is a pulsation artifact.  the corpus callosum is effaced.  there are extensive t2 signal abnormalities that are confluent in the corona radiata.  there are also scattered t2 abnormalities in the basal ganglia.  there is a suggestion of hippocampal atrophy.  there is also a suggestion of vermian atrophy.,assessment: , the patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  his examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  his mri scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,problems/diagnoses:,1.  possible idiopathic normal pressure hydrocephalus (331.5).,2.  probable cerebral small-vessel disease (290.40 & 438).,3.  gait impairment (781.2).,4.  urinary urgency and incontinence (788.33).,5.  dementia.,6.  hypertension.,7.  hypercholesterolemia.",21
"preoperative diagnoses:,1.  enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  a 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  a 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  a 1 cm x 1 cm actinic keratosis of the right mid cheek.,postoperative diagnoses:,1.  enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  a 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  a 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  a 1 cm x 1 cm actinic keratosis of the right mid cheek.,title of procedures:,1.  excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  a 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,anesthesia: , local.  i used a total of 6 ml of 1% lidocaine with 1:100,000 epinephrine.,estimated blood loss:,  less than 30 ml.,complications: , none.,counts:  ,sponge and needle counts were all correct.,procedure:,  the patient was evaluated preop and noted to be in stable condition.  chart and informed consent were all reviewed preop.  all risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  she is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  the areas of concern were marked with the marking pen.  local anesthetic was infiltrated.  sterile prep and drape were then performed.,i began excising the left upper cheek and left lower cheek neck lesions as listed above.  these were excised with the #15 blade.  the left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  a suture was placed at the 12 o'clock superior margin.  clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  the healthy margin of healthy tissue around this lesion was removed.  wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,the left upper neck lesion was also removed in the similar manner.  this is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  it was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  after wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,the lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the ellman radiofrequency wave unit.  these appeared to be clinically seborrheic keratotic neoplasms.,finally proceeded with the right cheek lesion, which was treated with the 50% tca.  this was also an actinic keratosis.  it is new in onset, just within the last week.  once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  postop care instructions have been reviewed in detail.  the patient is scheduled a recheck in one week for suture removal.  we will make further recommendations at that time.",37
"exam: , ultrasound carotid, bilateral.,reason for examination: , pain.,comparison:,  none.,findings: , bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery.  there are no different colors or spectral doppler waveform abnormalities.,parametric data:,  right cca psv 0.72 m/s.  right ica psv is 0.595 m/s.  right ica edv 0.188 m/s.  right vertebral 0.517 m/s. right ic/cc is 0.826. left cca psv 0.571 m/s, left ica psv 0.598 m/s.  left ica edv 0.192 m/s.  left vertebral 0.551 m/s.  left ic/cc is 1.047.,impression:,1.  no evidence for clinically significant stenosis.,2.  minimal, predominantly soft plaquing.,",3
"exam: , barium enema.,clinical history: , a 4-year-old male with a history of encopresis and constipation.,technique:  ,a single frontal scout radiograph of the abdomen was performed.  a rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  a post-evacuation overhead radiograph of the abdomen was performed.,findings:,  the scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  there are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  the visualized lung bases and osseous structures are within normal limits.,the rectum and colon is of normal caliber throughout its course.  there is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  a small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  there is also opacification of a normal-appearing appendix documented.,impression: , normal barium enema.",14
"problems and issues:,1.  headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and motrin for abortive treatment.,2.  some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,history of present illness: , the patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  i obtained and documented a full history and physical examination.  i reviewed the new patient questionnaire, which she completed prior to her arrival today.  i also reviewed the results of tests, which she had brought with her.,briefly, she is a 60-year-old woman initially from ukraine, who had headaches since age 25.  she recalls that in 1996 when her husband died her headaches became more frequent.  they were pulsating.  she was given papaverine, which was successful in reducing the severity of her symptoms.  after six months of taking papaverine, she no longer had any headaches.  in 2004, her headaches returned.  she also noted that she had ""zig-zag lines"" in her vision.  sometimes she would not see things in her peripheral visions.  she had photophobia and dizziness, which was mostly lightheadedness.  on one occasion she almost had a syncope.  again she has started taking russian medications, which did help her.  the dizziness and headaches have become more frequent and now occur on average once to twice per week.  they last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,past medical history: ,her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,medications:,  her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin d, centrum multivitamin tablets, actos, lorazepam as needed, vytorin, and celexa.,allergies: , she has no known drug allergies.,family history:  ,there is family history of migraine and diabetes in her siblings.,social history: , she drinks alcohol occasionally.,review of systems: , her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  remainder of her full 14-point review of system was unremarkable.,physical examination:,  on examination, the patient was pleasant.  she was able to speak english fairly well.  her blood pressure was 130/84.  heart rate was 80.  respiratory rate was 16.  her weight was 188 pounds.  her pain score was 0/10.  her general exam was completely unremarkable.  her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  she had reduced vibration sensation in her left ankle and to some degree in her right foot.  there was no ataxia.  she was able to walk normally.  reflexes were 2+ throughout.,she had had a ct scan with constant, which per dr. x's was unremarkable.  she reports that she had a brain mri two years ago which was also unremarkable.,impression and plan:,  the patient is a delightful 60-year-old chemist from ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  she has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  her diagnosis is consistent with vestibular migraine.  i do not see evidence of multiple sclerosis, ménière's disease, or benign paroxysmal positional vertigo.,i talked to her in detail about the importance of following a migraine diet.  i gave her instructions including a list of foods times, which worsen migraine.  i reviewed this information for more than half the clinic visit.  i would like to start her on amitriptyline at a dose of 10 mg at time.  she will take motrin at a dose of 800 mg as needed for her severe headaches.,she will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  i encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.",5
"cc:, headache and diplopia.,hx:, this 39 y/o african american female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. the pain localized to bifronto-temporal regions of the head and did not radiate. there was no associated nausea, vomiting, photophobia or phonophobia. the ha's occurred daily; and throughout daylight hours. they diminished at bedtime, but occasionally awakened her in the morning.,several days following the onset of her ha's, she began experiencing numbness and tingling about the right side of her face. these symptoms improved, but did not completely resolved.,several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. the diplopia resolved when covering either eye, and worsened upon looking toward the right. coincidentally, she began veering toward the right when walking. she denied any weakness. she had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. she was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,the patient was admitted locally 9/2/95. hct, 9/2/95 and brain mri with gadolinium, 9/3/95, were ""unremarkable."" lumbar puncture (done locally),9/3/95: opening pressure 27cm h20, csf analysis ( protein 14.0, glucose 66, o wbc, 3 rbc, vdrl non-reactive, lyme titer unremarkable, myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. esr=76. on 9/11/95 esr=110. acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ana and rf were negative. 7/94, ana and rf were negative, and esr=60.,meds: ,tylenol 500mg q5-6hrs. no known allergies.,pmh:, 1)juvenile rheumatoid arthritis diagnosed at age 10 years; now in remission. 2)right #5 finger reattachment as child due to traumatic amputation.,fhx: ,mother died age 42 of unknown type cancer. father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. one of the half-brothers has asthma.,shx: ,single, lives with sister, and denies tobacco/etoh/illicit drug use.,exam:, bp141/84, hr99, rr14, 36.8c, wt. 82kg ht. 152.,ms: a&o to person, place, time. speech fluent; without dysarthria. mood euthymic with appropriate affect.,cn: decreased abduction, od. in neutral gaze, the right eye deviated slightly lateral of midline. in addition, she had mild proptosis, od. the right eye was nontender to palpation during extraocular movement. visual fields were full to confrontation. optic disks appeared flat. face was symmetric with full movement and sensation. gag, shoulder shrug and corneal responses were intact, bilaterally. tongue was midline with full rom.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: unremarkable.,coord: unremarkable fnf/hks/ram.,station: unremarkable. no romberg's sign or drift.,gait: narrow based gait. able to tt and hw without difficulty. mild difficulty with tw.,reflexes: 2+/2+ throughout all 4 extremities. flexor plantar responses, bilaterally.,musculoskeletal: swan neck deformities of the #2 and #3 digits of both hands.,gen exam: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,course: ,repeat lumbar puncture yielded: opening pressure 20.25cm h20, protein 22, glucose 62, 2rbc, 1wbc. csf cytology, ace, cultures (bacterial, fungal, afb), gram stain, cryptococcal antigen, and vdrl were negative. serum ace, tsh, ft4 were unremarkable.,neuroophthalmology confirmed her right cn6 palsy and proptosis (od); and noted her complaint of paresthesias in the v1 and v2 distribution. they saw no evidence of papilledema. visual field testing was unremarkable. mri brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. cxr, 10/20/95, showed a lobulated mass arising from the right hilum. the mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. chest ct with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. there appeared to be calcification as well as low attenuation regions within the mass. no lymphadenopathy was noted. she underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, gms stains were negative and there was no evidence of viral changes, fungus or pcp by culture or molecular assay. she underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. no sign of cancer was found. tissue cultures (bacterial, fungal, afb) were negative times 3. the patients case was discussed at head and neck oncology tumor board and a differential diagnosis of sarcoidosis, histoplasmosis, wegener's granulomatosis, were considered. urine histoplasmosis antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. anca serum titers on 11/8/95 were <1:40 (normal). ppd testing was negative 11/95 (with positive candida and mumps controls).,the etiology of this patient's illness was not discovered. she was last seen 4/96 and her diplopia and right cn6 palsy had moderately improved.",21
"reason for consultation:,  this is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,past medical history: , hypertension.  the patient noncompliant,history of present complaint: , this 66-year-old patient has history of hypertension and has not taken medication for several months.  she is a smoker and she drinks alcohol regularly.  she drinks about 5 glasses of wine every day.  last drink was yesterday evening.  this afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  on arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  the patient received 5 mg of metoprolol iv, after which heart rate was reduced to the 70 and blood pressure was well controlled.  on direct questioning, the patient said she had been drinking a lot.  she had not had any withdrawal before.  today is the first time she has been close to withdrawal.,review of systems:,constitutional:  no fever.,ent:  not remarkable.,respiratory:  no cough or shortness of breath.,cardiovascular:  the patient denies chest pain.,gastrointestinal:  no nausea.  no vomiting.  no history of gi bleed.,genitourinary:  no dysuria.  no hematuria.,endocrine:  negative for diabetes or thyroid problems.,neurologic:  no history of cva or tia.,rest of review of systems is not remarkable.,social history:  ,the patient is a smoker and drinks alcohol daily in considerable amounts.,family history: , noncontributory.,physical examination:,general:  this is a 66-year-old lady with telangiectasia of the face.  she is not anxious at this moment and had no tremors.,chest:  clear to auscultation.  no wheezing.  no crepitations.  chest is tympanitic to percussion.,cardiovascular:  first and second heart sounds were heard.  no murmur was appreciated.,abdomen:  soft and nontender.  bowel sounds are positive.,extremities:  there is no swelling.  no clubbing.  no cyanosis.,neurologic:  the patient is alert and oriented x3.  examination is nonfocal.,diagnostic data: , ekg shows sinus tachycardia, no acute st changes.,laboratory data: , white count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  glucose is 124, bun is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  liver enzymes are within normal limits.  tsh is normal.,assessment and plan:,1.  uncontrolled hypertension.  we will start the patient on beta-blockers.  the patient is to see her primary physician within 1 week's time.,2.  tachycardia, probable mild withdrawal to alcohol.  the patient is stable now.  we will discharge home with diazepam p.r.n.  the patient had been advised that she should not take alcohol if she takes the diazepam.,3.  tobacco smoking disorder.  the patient has been counseled.  she is not contemplating quitting at this time.,disposition: , the patient is discharged home.,discharge medications:,1.  atenolol 50 mg p.o. b.i.d.,2.  diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  thiamine 100 mg p.o. daily.",15
"preoperative diagnoses:,1.  mass, left second toe.,2.  tumor.,3.  left hallux bone invasion of the distal phalanx.,postoperative diagnoses:,1.  mass, left second toe.,2.  tumor.,3.  left hallux with bone invasion of the distal phalanx.,procedure performed:,1.  excision of mass, left second toe.,2.  distal syme's amputation, left hallux with excisional biopsy.,history: , this 47-year-old caucasian male presents to abcd general hospital with a history of tissue mass on his left foot.  the patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  the patient also has history of shave biopsy in the past.  the patient does state that he desires surgical excision at this time.,procedure in detail:,  an iv was instituted by the department of anesthesia in the preoperative holding area.  the patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  copious amount of webril was placed around the left ankle followed by a blood pressure cuff.  after adequate sedation by the department of anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,the foot was then prepped and draped in the usual sterile orthopedic fashion.  the foot was elevated from the operating table and exsanguinated with an esmarch bandage.  care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  the foot was lowered to the operating table.  the stockinet was reflected and the foot was cleansed with wet and dry sponge.  a distal syme's incision was planned over the distal aspect of the left hallux.  the incision was performed with a #10 blade and deepened with #15 down to the level of bone.  the dorsal skin flap was removed and dissected in toto off of the distal phalanx.  there was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  the tissue was sent to pathology where dr. green stated that a frozen sample would be of less use for examining for cancer.  dr. green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  at this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  the area was inspected for any remaining suspicious tissues.  any suspicious tissue was removed.  the area was then flushed with copious amounts of sterile saline.  the skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,attention was then directed to the left second toe.  there was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  a linear incision was made just medial to the tissue mass.  the mass was then dissected from the overlying skin and off of the underlying capsule.  this tissue mass was hard, round, and pearly-gray in appearance.  it does not invade into any other surrounding tissues.  the area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  dressings consisted of owen silk soaked in betadine, 4x4s, kling, kerlix, and an ace wrap.  the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  the patient tolerated the above procedure and anesthesia well without complications.  the patient was transported to pacu with vital signs stable and vascular status intact.  the patient was given postoperative pain prescription for vicodin and instructed to follow up with dr. bonnani in his office as directed.  the patient will be contacted immediately pending the results of pathology.  cultures obtained in the case were aerobic and anaerobic gram stain, silver stain, and a cbc.",16
"chief complaint:  ,hip pain.,history of presenting illness:  ,the patient is a very pleasant 41-year-old white female that is known to me previously from our work at the pain management clinic, as well as from my residency training program, san francisco. we have worked collaboratively for many years at the pain management clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  she reports moderate to severe pain related to a complicated past medical history.  in essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  she was given nonsteroidals at that time, which did help with this discomfort.  with time, however, this became inadequate and she was seen later in san francisco in her mid 30s by dr. v, an orthopedist who diagnosed retroverted hips at hospital.  she was referred for rehabilitation and strengthening.  most of this was focused on her si joints.  at that time, although she had complained of foot discomfort, she was not treated for it.  this was in 1993 after which she and her new husband moved to the boston area, where she lived from 1995-1996.  she was seen at the pain center by dr. r with similar complaints of hip and knee pain.  she was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  medications at that time were salicylate and ultram.,when she returned to portland in 1996, she was then working for dr. b.  she was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  subsequently, nuclear bone scans revealed osteoarthritis.  orthotics were provided.  she was given paxil and tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  during this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  she has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  she currently does not have an established cardiologist having just changed insurance plans.  she is establishing care with dr. s, of rheumatology for her ongoing care.  up until today, her pain medications were being written by dr. y prior to establishing with dr. l.,pain management in town had been first provided by the office of dr. f. under his care, followup mris were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  a number of medications were attempted there, including fentanyl patches with flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  she then transferred her care to ab cd, fnp under the direction of dr. k.  her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,past medical history:  ,1.  attention deficit disorder.,2.  tmj arthropathy.,3.  migraines.,4.  osteoarthritis as described above.,past surgical history:,1.  cystectomies.,2.  sinuses.,3.  left ganglia of the head and subdermally in various locations.,4.  tmj and bruxism.,family history:  ,the patient's father also suffered from bilateral hip osteoarthritis.,medications:,1.  methadone 2.5 mg p.o. t.i.d.,2.  norco 10/325 mg p.o. q.i.d.,3.  tenormin 50 mg q.a.m.,4.  skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  wellbutrin sr 100 mg q.d.,6.  naprosyn 500 mg one to two pills q.d. p.r.n.,allergies: , iv morphine causes hives.  sulfa caused blisters and rash.,physical examination: , a well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,vital signs:  blood pressure 110/72 with a pulse of 68.,heent:  normocephalic.  atraumatic.  pupils are equal and reactive to light and accommodation.  extraocular motions are intact.  no scleral icterus.  no nystagmus.  tongue is midline.  mucous membranes are moist without exudate.,neck:  free range of motion without thyromegaly.,chest:  clear to auscultation without wheeze or rhonchi.,heart:  regular rate and rhythm without murmur, gallop, or rub.,abdomen:  soft, nontender.,musculoskeletal:  there is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the si joints bilaterally.  passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  toe-heel walking is performed without difficulty.  straight leg raises are negative.  romberg's are negative.,neurologic:  grossly intact.  intact reflexes in all extremities tested.  romberg is negative and downgoing.,assessment:,1. osteoarthritis.,2. chronic sacroiliitis.,3. lumbar spondylosis.,4. migraine.,5. tmj arthropathy secondary to bruxism.,6. mood disorder secondary to chronic pain.,7. attention deficit disorder, currently untreated and self diagnosed.,recommendations:,1. agree with rheumatology referral and review.  i would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. given the patient's previous sulfa allergies, we would recommend decreasing her naprosyn usage.",34
"preoperative diagnosis: , recurrent re-infected sebaceous cyst of abdomen.,postoperative diagnoses:,1.  abscess secondary to retained foreign body.,2.  incisional hernia.,procedures,1.  excision of abscess, removal of foreign body.,2.  repair of incisional hernia.,anesthesia: , lma.,indications: , patient is a pleasant 37-year-old gentleman who has had multiple procedures including a laparotomy related to trauma.  the patient has had a recurrently infected cyst of his mass at the superior aspect of his incision, which he says gets larger and then it drains internally, causing him to be quite ill.  he presented to my office and i recommended that he undergo exploration of this area and removal.  the procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,findings:,  the patient was found upon excision of the cyst that it contained a large prolene suture, which is multiply knotted as it always is; beneath this was a very small incisional hernia, the hernia cavity, which contained omentum; the hernia was easily repaired.,description of procedure: , the patient was identified, then taken into the operating room, where after induction of an lma anesthetic, his abdomen was prepped with betadine solution and draped in sterile fashion.  the puncta of the wound lesion was infiltrated with methylene blue and peroxide.  the lesion was excised and the existing scar was excised using an ellipse and using a tenotomy scissors, the cyst was excised down to its base.  in doing so, we identified a large prolene suture within the wound and followed this cyst down to its base at which time we found that it contained omentum and was in fact overlying a small incisional hernia.  the cyst was removed in its entirety, divided from the omentum using a metzenbaum and tying with 2-0 silk ties.  the hernia repair was undertaken with interrupted 0 vicryl suture with simple sutures.  the wound was then irrigated and closed with 3-0 vicryl subcutaneous and 4-0 vicryl subcuticular and steri-strips.  patient tolerated the procedure well.  dressings were applied and he was taken to recovery room in stable condition.",14
"reason for consultation: , i was asked by dr. x to see the patient in regard to his likely recurrent brain tumor.,history of present illness: , the patient was admitted for symptoms that sounded like postictal state.  he was initially taken to hospital.  ct showed edema and slight midline shift, and therefore he was transferred here.  he has been seen by hospitalists service.  he has not had a recurrent seizure.  electroencephalogram shows slowing.  mri of the brain shows large inhomogeneous infiltrating right frontotemporal neoplasm surrounding the right middle cerebral artery.  there is inhomogeneous uptake consistent with potential necrosis.  he also has had a spect image of his brain, consistent with neoplasm, suggesting relatively high-grade neoplasm.  the patient was diagnosed with a brain tumor in 1999.  all details are still not available to us.  he underwent a biopsy by dr. y. one of the notes suggested that this was a glioma, likely an oligodendroglioma, pending a second opinion at clinic.  that is not available on the chart as i dictate.,after discussion of treatment issues with radiation therapist and dr. z (medical oncologist), the decision was made to treat him primarily with radiation alone.  he tolerated that reasonably well.  his wife says it's been several years since he had a scan.  his behavior had not been changed, until it changed as noted earlier in this summary.,past medical history: , he has had a lumbar fusion.  i believe he's had heart disease.  mental status changes are either due to the tumor or other psychiatric problems.,social history:,  he is living with his wife, next door to one of his children.  he has been disabled since 2001, due to the back problems.,review of systems: , no headaches or vision issues.  ongoing heart problems, without complaints.  no weakness, numbness or tingling, except that related to his chronic neck pain.  no history of endocrine problems.  he has nocturia and urinary frequency.,physical examination: , blood pressure 146/91, pulse 76.  normal conjunctivae.  ears, nose, throat normal.  neck is supple.  chest clear.  heart tones normal.  abdomen soft.  positive bowel sounds.  no hepatosplenomegaly.  no adenopathy in the neck, supraclavicular or axillary regions.  neurologically alert.  cranial nerves are intact.  strength is 5/5 throughout.,laboratory work: , white blood count 10.4, hemoglobin 16, platelets not noted.  sodium 137, calcium 9.1.,impression and plan:,  likely recurrent low-grade tumor, possibly evolved to a higher grade, given the mri and spect findings.  dr. x's note suggests discussing the situation in the tumor board on wednesday.  he is stable enough.  the pause in his care would not jeopardize his current status.  it would be helpful to get old films and pathology from abbott northwestern.  however, he likely will need a re-biopsy, as he is highly suspicious for recurrent tumor and radiation necrosis.  optimizing his treatment would probably be helped by knowing his current grade of tumor.",16
"subjective:,  the patient presents with mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit.  mom wants to make sure that this is normal.  the patient is nursing well every two to three hours.  she does have some spitting up on occasion.  it has happened two or three times with some curdled appearance x 1.  no projectile in nature, nonbilious.  normal voiding and stooling pattern.  growth and development:  denver ii normal, passing all developmental milestones per age.  see denver ii form in the chart.,past medical history:,  mom reports uncomplicated pregnancy with prenatal care provided by dr. xyz in wichita, kansas.  delivery after induction secondary to postdate at st. joseph hospital.  infant delivered by svd with birth weight of 6 pounds 13 ounce.  length of 19 inches.  did well after delivery and dismissed to home with mom.  received hepatitis b #1 prior to dismissal.  no other hospitalizations.  no surgeries.  no known medical allergies.  no medications.  mom has tried mylicon drops on occasion.,family history: , significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents.  healthy mother, father.  there is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today.  there is history of asthma in the patient's father.,social history:,  the patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, john, who is a supervisor at excel.  the family lives in bentley, kansas.  no smoking in the home.  family does have one pet cat.,review of systems:,  as per hpi, otherwise, negative.,objective:,  weight:  7 pounds 12 ounces.  height:  21 inches.  head circumference:  35 cm.  temperature:  97.2 degrees.,general:  well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,heent:  atraumatic, normocephalic.  anterior fontanel is soft and flat.  pupils are equal, round and reactive.  sclerae clear.  red reflexes present bilaterally.  tms are clear bilaterally.  oropharynx:  mucous membranes are moist and pink.,neck:  supple, no lymphadenopathy.,chest:  clear to auscultation bilaterally.  no wheeze or crackles.  good air exchange.,cardiovascular:  regular rate and rhythm.  no murmur.  good pulses bilaterally.,abdomen:  soft, nontender, nondistended.  positive bowel sounds.  no mass nor organomegaly.,genitourinary:  tanner i female genitalia.  femoral pulses are equal bilaterally.  no rash.,extremities:  full range of motion.  no cyanosis, clubbing or edema.  negative ortolani or barlow maneuver.,back:  straight.  no scoliosis.,integument:  warm, dry and pink without lesions.,neurologic:  alert.  good muscle tone and strength.,assessment/plan:,1.  well 2-week-old white female.,2.  anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule.  gave 2-week well-child check handout and american academy of pediatrics book birth to 5 years to mom and family.,3.  call the office or on-call physician if the patient has fever, feeding problems or breathing problems.  otherwise plan to recheck at 1-month of age.",28
"procedure: , circumcision.,signed informed consent was obtained and the procedure explained.,the child was placed in a circumstraint board and restrained in the usual fashion.  the area of the penis and scrotum were prepared with povidone iodine solution.  the area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  a dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  a dorsal slit was made, and the prepuce was dissected away from the glans penis.  a ** gomco clamp was properly placed for 5 minutes.  during this time, the foreskin was sharply excised using a #10 blade.  with removal of the clamp, there was a good cosmetic outcome and no bleeding.  the child appeared to tolerate the procedure well.  care instructions were given to the parents.",38
"her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  motor strength was 5/5 on the mrc scale.  reflexes were 2+ and symmetrical.  palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,palpable trigger points were noted on today's evaluation.  she is suffering from ongoing myofascitis.  her treatment plan will consist of a series of trigger point injections, which were performed today.  she tolerated the procedure well.  i have asked her to ice the region intermittently for 15 minutes off and on x 3.  she will be followed in four weeks' time for repeat trigger point injections if indicated.,",26
"subjective: , review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with copd exacerbation.  the patient does have a longstanding history of copd.  however, she does not use oxygen at her independent assisted living home.  yesterday, she had made improvement since being here at the hospital.  she needed oxygen.  she was tested for home o2 and qualified for it yesterday also.  her lungs were very tight.  she did have wheezes bilaterally and rhonchi on the right side mostly.  she appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it.,overnight, the patient needed to use the rest room.  she stated that she needed to urinate.  she awoke, decided not to call for assistance.  she stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  she attempted to walk to the rest room on her own.  she sustained a fall.  she stated that she just felt weak.  she bumped her knee and her elbow.  she had femur x-rays, knee x-rays also.  there was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  this morning, she denied any headache, back pain or neck pain.  she complained mostly of right anterior knee pain for which she had some bruising and swelling.,objective:,vital signs:  the patient's max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  she is 95% on 2 l via nasal cannula.,heart:  regular rate and rhythm without murmur, gallop or rub.,lungs:  reveal no expiratory wheezing throughout.  she does have some rhonchi on the right mid base.  she did have a productive cough this morning and she is coughing green purulent sputum finally.,abdomen:  soft and nontender.  her bowel sounds x4 are normoactive.,neurologic:  she is alert and oriented x3.  her pupils are equal and reactive.  she has got a good head and facial muscle strength.  her tongue is midline.  she has got clear speech.  her extraocular motions are intact.  her spine is nontender on palpation from neck to lumbar spine.  she has good range of motion with regard to her shoulders, elbows, wrists and fingers.  her grip strengths are equal bilaterally.  both elbows are strong from extension to flexion.  her hip flexors and extenders are also strong and equal bilaterally.  extension and flexion of the knee bilaterally and ankles also are strong.  palpation of her right knee reveals no crepitus.  she does have suprapatellar inflammation with some ecchymosis and swelling.  she has got good joint range of motion however.,skin:  she did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently steri-stripped and wrapped with coban and is not actively bleeding.,assessment:,1.  acute on chronic copd exacerbation.,2.  community acquired pneumonia both resolving.  however, she may need home o2 for a short period of time.,3.  generalized weakness and deconditioning secondary to the above.  also sustained a fall secondary to instability and not using her walker or calling for assistance.  the patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.,plan:,1.  i will have pt and ot evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  myself and one of her daughter's spoke today about the fact that she generally lives independently at the brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.,2.  we will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.",3
"preoperative diagnosis:,  subglottic stenosis.,postoperative diagnosis: , subglottic stenosis.,operative procedures: , direct laryngoscopy and bronchoscopy.,anesthesia:,  general inhalation.,description of procedure: , the patient was taken to the operating room and placed supine on the operative table.  general inhalational anesthesia was administered through the patient's tracheotomy tube.  the small parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  there was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  the stoma showed some suprastomal fibroma.  the remaining tracheobronchial passages were clear.  the patient's 3.5 neonatal tracheostomy tube was repositioned and secured with velcro ties.  bleeding was negligible.  there were no untoward complications.  the patient tolerated the procedure well and was transferred to recovery room in stable condition.",11
"subjective:,  this is a 29-year-old vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  she comes in today as a referral from abc, d.o. for a reevaluation of her hand eczema.  i have treated her with aristocort cream, cetaphil cream, increased moisturizing cream and lotion, and wash her hands in cetaphil cleansing lotion.  she comes in today for reevaluation because she is flaring.  her hands are very dry, they are cracked, she has been washing with soap.  she states that the cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  she has been wearing some gloves also apparently.  the patient is single.  she is unemployed.,family, social, and allergy history: , the patient has asthma, sinus, hives, and history of psoriasis.  no known drug allergies.,medications: , the patient is a nonsmoker.  no bad sunburns or blood pressure problems in the past.,current medications:,  claritin and zyrtec p.r.n.,physical examination:,  the patient has very dry, cracked hands bilaterally.,impression:,  hand dermatitis.,treatment:,1.  discussed further treatment with the patient and her interpreter.,2.  apply aristocort ointment 0.1% and equal part of polysporin ointment t.i.d. and p.r.n. itch.,3.  discontinue hot soapy water and wash her hands with cetaphil cleansing lotion.,4.  keflex 500 mg b.i.d. times two weeks with one refill.  return in one month if not better; otherwise, on a p.r.n. basis and send dr. xyz a letter on this office visit.",34
"preoperative diagnosis:,  cataract, nuclear sclerotic, right eye.,postoperative diagnosis:,  cataract, nuclear sclerotic, right eye.,operative procedures: , phacoemulsification with intraocular lens implantation, right eye.,anesthesia: , topical tetracaine, intracameral lidocaine, monitored anesthesia care.,iol: , amo model si40 nb, power *** diopters.,indications for surgery: , this patient has been experiencing difficulty with eyesight regarding activities in their daily life.  there has been a progressive and gradual decline in the visual acuity.  by examination, this was found to be related to cataracts.  the risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  the patient accepted these risks and elected to proceed with cataract surgery.  all questions were answered and informed consent was obtained.,questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  a preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  to minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,description of procedure:  ,the patient was identified and the procedure was verified.  the pupil was dilated per protocol.  the patient was taken to the operating room and placed in a comfortable supine position.  the operative table was placed in trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  the patient was prepped and draped in the usual ophthalmic sterile fashion.  the lids and periorbita were prepped with full-strength betadine solution with care taken to concentrate on sterilizing the eyelid margins.  the conjunctival cul-de-sac was also prepped in dilute betadine solution.  the fornices were also prepped.  the drape was done meticulously to ensure complete eyelash inclusion.,an eyelid speculum was placed to separate the eyelids.  a paracentesis site was made.  intracameral preservative-free lidocaine was injected.  amvisc plus was then used to stabilize the anterior chamber.  a 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  a 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  the capsular flap was removed.  a 27-gauge blunt cannula was used for hydrodissection.  the lens was able to be freely rotated within the capsular bag.  divide-and-conquer technique was used for phacoemulsification.  after four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and koch spatula was used to separate and crack each grooved segment.  each of the four nuclear quadrants was phacoemulsified.  aspiration was used to remove remaining cortex with the i/a handpiece.  viscoelastic was used to re-inflate the capsular bag.  the intraocular lens was injected into the capsular bag.  the lens was then dialed into position.  the lens was well-centered and stable.  viscoelastic was aspirated.  bss was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  a weck-cel sponge was used to check both incision sites for leaks and none were identified.  the incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  the eyelid speculum was removed and the patient was cleaned free of betadine.  zymar and pred forte drops were applied.  a firm eye shield was taped over the operative eye.  the patient was then taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  all questions were answered.  the discharge instructions were also reviewed with the patient by the discharging nurse.  the patient was comfortable and was discharged with followup in 24 hours.",25
"reason for consultation:,  metastatic ovarian cancer.,history of present illness: , mrs. abcd is a very nice 66-year-old woman who is followed in clinic by dr. x for history of renal cell cancer, breast cancer, as well as ovarian cancer, which was initially diagnosed 10 years ago, but over the last several months has recurred and is now metastatic.  she last saw dr. x in clinic towards the beginning of this month.  she has been receiving gemcitabine and carboplatin, and she receives three cycles of this with the last one being given on 12/15/08.  she was last seen in clinic on 12/22/08 by dr. y.  at that point, her white count was 0.9 with the hemoglobin of 10.3, hematocrit of 30%, and platelets of 81,000.  her anc was 0.5.  she was started on prophylactic augmentin as well as neupogen shots.  she has also had history of recurrent pleural effusions with the knee for thoracentesis.  she had two of these performed in november and the last one was done about a week ago.,over the last 2 or 3 days, she states she has been getting more short of breath.  her history is somewhat limited today as she is very tired and falls asleep readily.  her history comes from herself but also from the review of the records.  overall, her shortness of breath has been going on for the past few weeks related to her pleural effusions.  she was seen in the emergency room this time and on chest x-ray was found to have a new right-sided pulmonic consolidative infiltrate, which was felt to be possibly related to pneumonia.  she specifically denied any fevers or chills.  however, she was complaining of chest pain.  she states that the chest pain was located in the substernal area, described as aching, coming and going and associated with shortness of breath and cough.  when she did cough, it was nonproductive.  while in the emergency room on examination, her vital signs were stable except that she required 5 liters nasal cannula to maintain oxygen saturations.  an ekg was performed, which showed sinus rhythm without any evidence of q waves or other ischemic changes.  the chest x-ray described above showed a right lower lobe infiltrate.  a v/q scan was done, which showed a small mismatched defect in the left upper lobe and a mass defect in the right upper lobe.  the findings were compatible with an indeterminate study for a pulmonary embolism.  apparently, an ultrasound of the lower extremities was done and was negative for dvt.  there was apparently still some concern that this might be pulmonary embolism and she was started on lovenox.  there was also concern for pneumonia and she was started on zosyn as well as vancomycin and admitted to the hospital.,at this point, we have been consulted to help follow along with this patient who is well known to our clinic.,past medical history,1.  ovarian cancer - this was initially diagnosed about 10 years ago and treated with surgical resection including tah and bso.  this has recurred over the last couple of months with metastatic disease.,2.  history of breast cancer - she has been treated with bilateral mastectomy with the first one about 14 years and the second one about 5 years ago.  she has had no recurrent disease.,3.  renal cell carcinoma - she is status post nephrectomy.,4.  hypertension.,5.  anxiety disorder.,6.  chronic pain from neuropathy secondary to chemotherapy from breast cancer treatment.,7.  ongoing tobacco use.,past surgical history,1.  recent and multiple thoracentesis as described above.,2.  bilateral mastectomies.,3.  multiple abdominal surgeries.,4.  cholecystectomy.,5.  remote right ankle fracture.,allergies:,  no known drug allergies.,medications: , at home,,1.  atenolol 50 mg daily,2.  ativan p.r.n.,3.  clonidine 0.1 mg nightly.,4.  compazine p.r.n.,5.  dilaudid p.r.n.,6.  gabapentin 300 mg p.o. t.i.d.,7.  k-dur 20 meq p.o. daily.,8.  lasix unknown dose daily.,9.  norvasc 5 mg daily.,10.  zofran p.r.n.,social history: , she smokes about 6-7 cigarettes per day and has done so for more than 50 years.  she quit smoking about 6 weeks ago.  she occasionally has alcohol.  she is married and has 3 children.  she lives at home with her husband.  she used to work as a unit clerk at xyz medical center.,family history:,  both her mother and father had a history of lung cancer and both were smokers.,review of systems: , general/constitutional:  she has not had any fever, chills, night sweats, but has had fatigue and weight loss of unspecified amount.  heent:  she has not had trouble with headaches; mouth, jaw, or teeth pain; change in vision; double vision; or loss of hearing or ringing in her ears.  chest:  per the hpi, she has had some increasing dyspnea, shortness of breath with exertion, cough, but no sputum production or hemoptysis.  cvs:  she has had the episodes of chest pains as described above but has not had, pnd, orthopnea lower extremity swelling or palpitations.  gi:  no heartburn, odynophagia, dysphagia, nausea, vomiting, diarrhea, constipation, blood in her stool, and black tarry stools.  gu:  no dysuria, burning with urination, kidney stones, and difficulty voiding.  musculoskeletal:  no new back pain, hip pain, rib pain, swollen joints, history of gout, or muscle weakness.  neurologic:  she has been diffusely weak but no lateralizing loss of strength or feeling.  she has some chronic neuropathic pain and numbness as described above in the past medical history.  she is fatigued and tired today and falls asleep while talking but is easily arousable.  some of this is related to her lack of sleep over the admission thus far.,physical examination,vital signs:  her t-max is 99.3.  her pulse is 54, her respirations is 12, and blood pressure 118/61.,general:  somewhat fatigued appearing but in no acute distress.,heent:  nc/at.  sclerae anicteric.  conjunctiva clear.  oropharynx is clear without any erythema, exudate, or discharge.,neck:  supple.  nontender.  no elevated jvp.  no thyromegaly.  no thyroid nodules.,chest:  clear to auscultation and percussion bilaterally with decreased breath sounds on the right.,cvs:  regular rate and rhythm.  no murmurs, gallops or rubs.  normal s1 and s2.  no s3 or s4.,abdomen:  soft, nontender, nondistended.  normoactive bowel sounds.  no guarding or rebound.  no hepatosplenomegaly.  no masses.",16
"chief complaint:,  follicular non-hodgkin's lymphoma.,history of present illness: , this is an extremely pleasant 69 year-old gentleman, who i follow for his follicular lymphoma.  his history is that in february of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-hodgkin's lymphoma.  from 03/29/88 to 08/02/88, he received six cycles of chop chemotherapy.  in 1990, his ct scan showed retroperitoneal lymphadenopathy.  therefore from 04/02/90 to 08/20/90, he received seven cycles of cvp.  in 1999, he was treated with m-bacod.  he also received radiation to his pelvis.  on 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  his most recent pet scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,overall, he is doing well.  he has a good energy level, his ecog performance status is 0.  he denies any fever, chills or night sweats.  no lymphadenopathy.  no nausea or vomiting.  no change in bowel or bladder habits.,current medications: , avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., coumadin 5 mg on monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., coreg 6.25 mg b.i.d., vasotec 2.5 mg b.i.d., zantac 150 mg q.d., claritin d q.d., centrum q.d., calcium q.d., omega-3 b.i.d., metamucil q.d., and lasix 40 mg t.i.d.,allergies: , no known drug allergies.,review of systems:  ,as per the hpi, otherwise negative.,past medical history:,1.  he has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  he had bilateral ureteral obstruction and is status post a stent placement.  the obstruction was secondary to his pelvic radiation.,3.  history of congestive heart failure.,4.  history of schwannoma resection.  it was resected from t12 to l1 in 1991.,5.  he has chronic obstruction of his inferior vena cava.,6.  recurrent lower extremity cellulitis.,social history:  ,he has no tobacco use.  no alcohol use.  he is married.  he is a retired methodist minister.,family history: , his mother just died two days ago.  there is no history of solid tumors or hematologic malignancies in his family.,physical exam:,vit:",34
"diagnoses:,1.  pneumonia.,2.  crohn disease.,3.  anasarca.,4.  anemia.,chief complaint: , i have a lot of swelling in my legs.,history:  ,the patient is a 41-year-old gentleman with a long history of crohn disease.  he has been followed by dr. abc, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  he has been treated with multiple different medications for his crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  this has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  he has been treated with iv antibiotics and is growing streptococcus.  at this time, he seems relatively stable although slightly dyspneic.  other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  at this time, he continues to have symptoms consistent with diarrhea and malabsorption.  he also has some episodes of nausea and vomiting at times.  he currently has a cough and symptoms of dyspnea.  further review of systems was not otherwise contributory.,medications:,1.  prednisone.,2.  effexor.,3.  folic acid.,4.  norco for pain.,past medical history: , as mentioned above, but he also has anxiety and depression.,past surgical history:,1.  small bowel resections.,2.  appendectomy.,3.  a vasectomy.,allergies:  ,he has no known drug allergies.,social history:  ,he does smoke two packs of cigarettes per day.  he has no alcohol or drug use.  he is a painter.,family history:  ,significant for his father who died of ipf and irritable bowel syndrome.,review of systems: , as mentioned in the history of present illness and further review of systems is not otherwise contributory.,physical examination:,general:  he is a thin appearing man in very mild respiratory distress when his oxygen is off.,vital signs:  his respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,heent:  sclerae anicteric.  conjunctivae normal.  nasal and oropharynx are clear.,neck:  supple.  no jugular venous pressure distention is noted.  there is no adenopathy in the cervical, supraclavicular or axillary areas.,chest:  reveals some crackles in the right chest, in the base, and in the upper lung fields.  his left is relatively clear with decreased breath sounds.,heart:  regular rate and rhythm.,abdomen:  slightly protuberant.  bowel sounds are present.  he is slightly tender and it is diffuse.  there is no organomegaly and no ascites appreciable.,extremities:  there is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,dermatologic:  shows thin skin.  no ecchymosis or petechiae.,laboratory studies: , laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  there is no m-spike observed.  his b12 is 500 with a folic acid of 11.  his white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,impression at this time:,1.  pneumonia in the face of fairly severe crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  he also has anemia and leukocytosis, which may be related to his crohn disease as well as his underlying pneumonia.,assessment and plan: , at this time, i believe evaluation of protein intake and dietary supplement will be most appropriate.  i believe that he needs a calorie count.  we will check on a sedimentation rate, c-reactive protein, ldh, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  i have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  i will help in anyway that i can to improve the patient's laboratory abnormalities.  however, his lower extremity edema is primarily due to his marked hypoalbuminemia and i do not believe that diuretics will help him at this time.  i have explained this in detail to the patient and his family.  everybody expresses understanding and all questions were answered.  at this time, follow him up during his hospital stay and plan to see him in the office as well.",5
"diagnosis:  ,shortness of breath.  fatigue and weakness.  hypertension.  hyperlipidemia.,indication: , to evaluate for coronary artery disease.,",32
"preoperative diagnosis: , rotator cuff tear, right shoulder.,postoperative diagnosis: , superior labrum anterior and posterior lesion (peel-back), right shoulder.,procedure performed:,1.  arthroscopy with arthroscopic slap lesion.,2.  repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,specifications: , the entire operative procedure was done in inpatient operating suite, room #1 at abcd general hospital.  this was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,history and gross findings:  ,this is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  she had an injury to her right shoulder when she fell off a bike.  she was diagnosed preoperatively with a rotated cuff tear.,intra-articularly besides we noted a large slap lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  this acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  this was an obvious avulsion into subchondral bone with bone exposed.  the anterior aspect had degenerative changes, but did not have evidence of avulsion.  the subscapular was noted to be intact.  on the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,this was confirmed subacromially.  the patient had a type-i plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the ca ligament in a releasing resection type fashion.,operative procedure: , the patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the anesthesia department.  she was safely placed in a modified beachchair position.  she was prepped and draped in the usual sterile manner.  the portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  she had at least two other portals appropriate for both repair mechanisms described above.,attention was then turned to the slap lesion.  the edges were debrided both on the bony side as well as soft tissue side.  we used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  further debridement was carried out here.  a drill hole was made just on the articular surface superiorly for a knotless anchor.  a pull-through suture of #2 fiber wire was utilized with the ________.  this was pulled through.  it was tied to the leader suture of the knotless anchor.  this was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  there was excellent fixation of the superior labrum.  it was noted to be solid and intact.  the anchor was placed safely in the bone.  there was no room for further knotless or other anchors.  after probing was carried out, hard copy polaroid was obtained.,attention was then turned to the articular side for the rotator cuff.  it was debrided.  subchondral debridement was carried out to the tuberosity also.  care was taken to go to the subchondral region but not beyond.  the bone was satisfactory.,scope was then placed in the subacromial region.  gross bursectomy was carried out with in the lateral portal.  this was done throughout as well as in the gutters anterolaterally and posteriorly.  debridement was carried out further to the rotator cuff.  two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after pds leader suture placed with a caspari punch.  there was an excellent reduction of the tear posteriorly and then anteriorly.  tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  this was done with a sliding stitch and then two half stitches.  there was excellent reduction of the tear.,attention was then turned to the ca ligament.  it was released along with periosteum and the undersurface of the anterior acromion.  the ca ligament was not only released but resected.  there was noted to be no evidence of significant spurring with only a mostly type-i acromion.  thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  a pain buster catheter was placed separately.  it was cut to length.  an interrupted #4-0 nylon was utilized for portal closure.  a 0.5% marcaine was instilled subacromially.  adaptic, 4x4s, abds, and elastoplast tape placed for dressing.  the patient's arm was placed in a arm sling.  she was transferred to pacu in apparent satisfactory condition.  expected surgical prognosis on this patient is fair.",37
"history of present illness:,  this is a 41-year-old registered nurse (r.n.).  she was admitted following an overdose of citalopram and warfarin.  the patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.  she notes starting in january, her husband of five years seemed to be quite withdrawn.  it turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman.  the patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him.  they had moved to abcd where he had recently been employed as a restaurant manager.  she also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her.  she has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue.  some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder.  in january, she went on citalopram.  she reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,past and developmental history: , she was born in xyz.  she describes the family as being somewhat dysfunctional.  father was a truckdriver.  she is an only child.  she reports that she had a history of anorexia and bulimia as a teenager.  in her 20s, she served six years in naval reserve.  she was previously married for four years.  she described that as an abusive relationship.  she had a history of being in counseling with abc, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,physical examination:  ,general:  this is an alert and cooperative woman.,vital signs:  temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,psychiatric:  she makes good eye contact.  speech is normal in rate, volume, grammar, and vocabulary.  there is no thought disorder.  she denies being suicidal.  her affect is appropriate for material being discussed.  she has a sense of future, wants to get back to work, has plans to return to counseling.  she appeared to have normal orientation, concentration, memory, and judgment.,medical history is notable for factor v leiden deficiency, history of pulmonary embolus, restless legs syndrome.  she has been off her mirapex.  i did encourage her to go back on the mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,the patient at this time can contract for safety.  she has made plans for outpatient counseling this saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,laboratory data: , inr, which is still 8.8.  in 1998, she had a normal mri.  electrolytes, bun, creatinine, and cbc were all normal.,diagnoses:  ,1.  seasonal depressive disorder.,2.  restless legs syndrome.,3.  overdose of citalopram and warfarin.,recommendations: , the patient reports she has been feeling better since discontinuing antidepressants.  i, therefore, recommend she stay off antidepressants at present.  if needed, she can take prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation.  she does give a fairly good history of seasonal depression and given that her mood has improved in the past with prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,please feel free to contact me at digital pager if there is additional information i can provide.",31
"preoperative diagnosis:,  cervical adenocarcinoma, stage i.,postoperative diagnosis: , cervical adenocarcinoma, stage i.,operation performed:,  exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,anesthesia: , general, endotracheal tube.,specimens: , uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,indications for procedure:,  the patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  she was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,findings: , during the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  during the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  there was no evidence of intraperitoneal spread or lymphadenopathy.  ,operative procedure:  ,the patient was brought to the operating room with an iv in place.  anesthetic was administered after which she was examined under anesthesia.  the vagina was then prepped and a foley catheter was placed.  she was prepped and draped.  a pfannenstiel incision was made three centimeters above the symphysis pubis.  the peritoneum was entered and the abdomen was explored with findings as noted.  the bookwalter retractor was placed, and bowel was packed.  clamps were placed on the broad ligament for traction.  the retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  the round ligaments were isolated, divided and ligated.  the peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  the pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  the utero-ovarian ligaments were then isolated, divided and doubly ligated.  tubes and ovaries were mobilized.  the ureters were dissected free from the medial leaf of the peritoneum.  when the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  the uterine artery pedicle was dissected anteriorly over the ureter.  the ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  this was continued until the insertion point of the ureter into the bladder trigone.  the peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  clamps were placed on the uterosacral ligaments at their point of origin.  tissues were divided and suture ligated.  clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  the vagina was then clamped and divided at the junction between the middle and upper third.  the vaginal vault was closed with interrupted figure-of-eight stitches.  excellent hemostasis was noted.,retractors were repositioned in the retroperitoneum for the lymphadenectomy.  the borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  the obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  ligaclips were applied where necessary.  after removal of the lymph node specimens, the pelvis was irrigated.  the ovaries were transposed above the pelvic brim using running stitches.  packs and retractors were removed, and peritoneum was closed with a running stitch.  subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  subcutaneous adipose was irrigated, and scarpa's fascia was closed with a running stitch.  skin was closed with a running subcuticular stitch.  final sponge, needle, and instrument counts were correct at the completion of the procedure.  the patient was awakened from the anesthetic and taken to the post anesthesia care unit in stable condition.",23
"preoperative diagnoses:,1.  gastroesophageal reflux disease.,2.  hiatal hernia.,postoperative diagnoses:,1.  gastroesophageal reflux disease.,2.  hiatal hernia.,3.  enterogastritis.,procedure performed:  ,esophagogastroduodenoscopy, photography, and biopsy.,gross findings: , the patient has a history of epigastric abdominal pain, persistent in nature.  she has a history of severe gastroesophageal reflux disease, takes pepcid frequently.  she has had a history of hiatal hernia.  she is being evaluated at this time for disease process.  she does not have much response from protonix.,upon endoscopy, the gastroesophageal junction is approximately 40 cm.  there appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  there is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  however there appeared to be inflammation as stated previously in the gastroesophageal junction.  there was some mild inflammation at the antrum of the stomach.  the fundus of the stomach was within normal limits.  the cardia showed some laxity to the lower esophageal sphincter.  the pylorus is concentric.  the duodenal bulb and sweep are within normal limits.  no ulcers or erosions.,operative procedure: , the patient is taken to the endoscopy suite, prepped and draped in the left lateral decubitus position.  the patient was given iv sedation using demerol and versed.  olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  photographs were taken with the pathology present.  biopsy was obtained of the antrum of the stomach and also clo test.  the biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult barrett's esophagitis.  air was aspirated from the stomach and the panendoscope was removed.  the patient sent to recovery room in stable condition.",14
"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.",31
"preoperative diagnoses:,1.  abnormal uterine bleeding.,2.  status post spontaneous vaginal delivery.,postoperative diagnoses:,1.  abnormal uterine bleeding.,2.  status post spontaneous vaginal delivery.,procedure performed:,1.  dilation and curettage (d&c).,2.  hysteroscopy.,anesthesia: , iv sedation with paracervical block.,estimated blood loss:,  less than 10 cc.,indications:  ,this is a 17-year-old african-american female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  the patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,procedure:,  the patient was consented and seen in the preoperative suite.  she was taken to the operative suite, placed in a dorsal lithotomy position, and placed under iv sedation.  she was prepped and draped in the normal sterile fashion.  her bladder was drained with the red robinson catheter which produced approximately 100 cc of clear yellow urine.  a bimanual exam was done, was performed by dr. x and dr. z.  the uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  the cervix and vagina were grossly normal with no obvious masses or deformities.  a weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,the uterus was sounded to 8 cm.  the cervix was sterilely dilated with hank dilator and then hagar dilator.  at the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  the dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  under direct visualization, the ostia were within normal limits.  the endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  the hyperplastic tissue did not appear to have calcification or other abnormalities.  there was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  the hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  the endometrial sampling was placed on telfa pad and sent to pathology for evaluation.  a rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  there was a normal consistency of the cervix and the normal step-off.  the uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  the cervix was found to be hemostatic.  the patient was taken off the dorsal lithotomy position and recovered from her iv sedation in the recovery room.  the patient will be sent home once stable from anesthesia.  she will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  the patient is sent home on tylenol #3 prescription as she is allergic to motrin.  the patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  the patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.",23
"chief complaint: , vaginal discharge with a foul odor.,history of present illness: , this is a 25-year-old african-american female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  the patient states that she has also had frequency of urination.  the patient denies any burning with urination.  she states that she is sexually active and does not use condoms.  she does have three sexual partners.  the patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  the patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  the patient does state that she has never had hiv testing.  the patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  the patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  the patient also denies skin rashes or lesions.  she does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  the patient is g2 p2.  she has had some irregular pap smears in the past.  her last pap smear was approximately 6 to 12 months ago.  the patient has had frequent urinary tract infections in the past.,past medical history:,1.  bronchitis.,2.  urinary tract infections.,3.  vaginal candidiasis.,past surgical history: , cyst removal of the right breast.,social history: , the patient does smoke approximately half a pack of cigarettes per day.  she denies alcohol or illicit drug use.,medications: , none.,allergies:,  no known medical allergies.,physical examination:,general:  this is an african-american female who appears her stated age of 25 years.  she is well nourished, well developed, and in no acute distress.  the patient is pleasant.,vital signs:  afebrile.  blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,heart:  regular rate and rhythm.  clear s1 and s2.  no murmur, rub or gallop is appreciated.,lungs:  clear to auscultation bilaterally.  no wheezes, rales or rhonchi.,abdomen:  soft, nontender, nondistended.  positive bowel sounds throughout.,skin:  warm, dry and intact.  no rash or lesion.,psych:  alert and oriented to person, place, and time.,neurologic:  cranial nerves ii through xii are intact bilaterally.  no focal deficits are appreciated.,genitourinary:  the pelvic exam done shows external genitalia without abnormalities or lesions.  there is a white-to-yellow discharge.  transformation zone is identified.  the cervix is mildly friable.  vaginal vault is without lesions.  there is no adnexal tenderness.  no adnexal masses.  no cervical motion tenderness.  cervical swabs and vaginal cultures are obtained.,diagnostic studies: , urinalysis shows 3+ bacteria, however, there are no wbc's.  no squamous epithelial cells and no other signs of infection.  there is no glucose.  the patient's cervical swabs and cultures are obtained and there are positive clue cells.  negative trichomonas.  negative fungal elements and chlamydia and gonorrhea are pending at this time.  urinalysis is sent for culture and sensitivity.,assessment:,: gardnerella bacterial vaginosis.,plan: , the patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  the patient will follow up with her primary care provider.,",12
"preoperative diagnosis: , acute abdominal pain, rule out appendicitis versus other.,postoperative diagnosis:,  acute pelvic inflammatory disease and periappendicitis.,procedure performed: , diagnostic laparoscopy.,complications:,  none.,cultures:,  intra-abdominally are done.,history:  ,the patient is a 31-year-old african-american female patient who complains of sudden onset of pain and has seen in the emergency room.  the pain has started in the umbilical area and radiated to mcburney's point.  the patient appears to have a significant pain requiring surgical evaluation.  it did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  the patient was seen by dr. y at my request in the er with me in attendance.  we went over the case.  he decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  the patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  the patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  the patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  the patient has had hospitalization for this.  the patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  all questions were answered.  ,procedure: ,the patient was seen in the emergency room.  in the emergency room, there is really no apparent vaginal discharge.  no odor or cervical motion tenderness.  negative bladder sweep.  adnexa were without abnormalities.  in the or, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  the patient had no adnexal fullness.  the patient then underwent an insertion of a uterine manipulator and dr. x was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  we then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  the both fallopian tubes were seen.  there did not appear to be hydrosalpinx.  the ovaries were seen.  the left showed some adhesions into the ovarian fossa.  the cul-de-sac had a banded adhesions.  the patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  the ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  the patient's bowel was otherwise unremarkable.  the liver contained evidence of fitz-hugh-curtis syndrome and prior pid.  the appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  the case was then turned over to dr. y who was in the room at that time and dr. x had left.  the patient's case was turned over to him.  dr. y was performed an appendectomy following which cultures and copious irrigation.  dr. y was then closed the case.  the patient was placed on antibiotics.  we await the results of the cultures and as well further ______ therapy.,primary diagnoses:,1.  periappendicitis.,2.  pelvic inflammatory disease.,3.  chronic adhesive disease.",23
"preoperative diagnoses:,1.  right ankle trimalleolar fracture.,2.  right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,operative procedure:  ,delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,postoperative diagnoses:,1.  right ankle trimalleolar fracture.,2.  right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,tourniquet time: , 80 minutes.,history: , this 50-year-old gentleman was from the area and riding his motorcycle in kentucky.,the patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  he was on a curve and lost control.  he is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  there were no other injuries.  he was treated in kentucky.  a close reduction was performed and splint applied.  orthopedic surgeon called myself with regards to this patient's fracture management and suggested a ct scan.  the patient returned to ohio and his friend drove him all the way from kentucky to northwest ohio overnight.  the patient showed up in the emergency department where a ct scan was asked to be performed.  this was performed and reviewed.  the patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  at this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  the patient was x-rayed in the office.  he had lost some of his reduction.  therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,an x-ray showed the distal fibular fracture starting at the mortise region laterally.  it appeared as an abduction type injury with minimal rotation.  this was comminuted, fragmented, and impacted.,the medial malleolus fracture was an avulsion type.  the syndesmosis appeared to be intact.  this appeared as an ao type b fracture.  however, this was not a rotational injury.,there is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  ct scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  a posterior tillaux fragment appeared to be separate.  however, in this area, there was significant comminution in the mid portion of the ankle joint.,there were many fragments and defects in this region.,the medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,we discussed delayed open reduction internal fixation with the patient.  he understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  we discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the ct scan.  we discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  we discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,the patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,the patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  we discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  we did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  he understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,we discussed the posterolateral approach with reduction of the fibula.  we discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  he understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  with this, the patient understood that the hardware may necessitate removal as well in the future.  we discussed hardware irritation.  we also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  with these risks discussed and listed on the consent, the patient wanted the procedure.,operative note:,  the patient was brought to operating theater and given successful general anesthetic.  his right leg was prepped and draped in the usual fashion.  before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  it was felt that at one point the posterior tibialis tendon may be intraarticular.,the reduction appeared to line up.  however, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,a lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  the superficial peroneal nerve was seen and this was avoided.  the incision was placed posterolateral to fibula.,this was to ensure good flap of tissue between the 2 incisions medial and laterally.  the fracture was seen.  the fracture was elevated and medialized and de-rotated.  the anterior portion of the distal fibula was significantly comminuted with defect.  the posterior aspect was still intact.  however, there were multiple fracture lines demonstrating a crush-type injury.  this was reduced manually.  at this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  no sharp dissection was performed.  the posterior malleolar fragment was palpated with the distal fibula reduced.  the posterior malleolar fragment appeared to be reduced as well.,x-ray views confirmed this.,an incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  this was taken only through subcutaneous tissue.  the saphenous vein was found, dissected out.  its branches were cauterized.  penrose drain was placed around this.,dissection was undertaken.  the periosteal tissue was seen and was invaginated into the joint.,this was recovered and flipped back on both sides.  next, the towel clip was used.  ends were freshened up using irrigation.  the joint surface appeared to be congruent anteriorly and posteriorly medially.,anatomic reduction was performed in the medial malleolus using 2 mm k-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  anatomic reduction was gained.  x-rays were taken showing excellent anatomic reduction.  next, attention was drawn towards the fibula.  standard 6-hole one-third tubular plate was applied to this.  again, this was more of a transverse impacted fracture.  therefore, interfragmentary screw on an angle could not be used.,the posterior cortex was used to assess anatomic reduction.  screws were placed.  it was used as a spring plate pushing the distal fibular fragment medially.,screw holes were filled.  they were double-checked.  screws had excellent purchase and were tightened up.  at this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  this appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,the screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,a 2 mm k-wire was used.  finger was placed on this fragment and the pin was advanced even before the finger.  x-ray views could show the posterior cortex and location of the pin.  this was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  this was double checked to ensure good positioning and this was so.  on the lateral view, we could see this was not in the joint.  ap views and mortise views showed this was not in the joint.  one could palpate this as well.  the screw was placed slightly proximal to distal in the anteroposterior plane.  at the distal tip of it, it was just in the subchondral bone but not in the joint.  there was slight to excellent purchase of this posterior lateral fragment.  wounds were copiously irrigated followed by closing using 2-0 vicryl in inverted fashion followed by staples to skin.  adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with kerlix followed by an extensor bandage.  posterior splint was placed on the patient.  the patient's leg was placed in neutral position.  significant amount of cast padding were used and large bulky trauma abd type dressings.  the heel was padded and leg was padded with approximately 2 inches of padding.  tourniquet was deflated.  the patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  positioning of the leg was accomplished by the physician assistant.  as well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  the patient is expected to do well overall.  he does have an area of comminution shown on the ct scan.  however, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.",26
"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.",32
"reason for referral: , cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain.,history:,  this is a 77-year-old white female patient whom i have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at halifax medical center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries.  since then, she has generally done well.  she used to be seeing another cardiologist and apparently she had a stress test in september 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.,the patient had been on medical therapy at home and generally doing well.  recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.  she denies any rest or exertional chest discomfort.  yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m.  the discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding.  later on she was nauseous, but she did not have any vomiting.  she denied any diarrhea.  no history of fever or chills.  since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same.  she was given morphine, zofran, demerol, another zofran, and reglan as well as demerol again and she was given intravenous fluids.  subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning.  the patient was admitted however for further workup and treatment.  at the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind.  she has not been fed any food, however.  the patient also had had pelvis and abdominal ct scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area.  the patient has had left nephrectomy and splenectomy, which has been described.  a 1.5-mm solid mass is described to be in the lower pole of the kidney.  the patient also has been described to have diverticulosis without diverticulitis on this finding.,currently however, the patient has no clinical symptoms according to her.,past medical history:,  she has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so.  she had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated.  she has a small myocardial infarction and then she was under the care of dr. a and she had aortocoronary bypass surgery at halifax medical center by dr. b, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.,she had had nuclear stress test with dr. c on september 3, 2008, which was described to be abnormal with ischemic defects, but i do not think the patient had any further cardiac catheterization and coronary angiography after that.  she has been treated medically.,this patient also had an admission to this hospital in may 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis.  she was described to have had a hemorrhagic cyst of the right kidney.  she has mild arthritis for the last 10 or 15 years.  she has a history of gerd for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding.  she has a history of diverticulosis as mentioned.  no history of tia or cva.  she has one kidney.  she was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture.  the patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery.  she describes this to be a clot on left lung.  i am not sure if she had any long-term treatment, however.,in the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978.,family history: , her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer.  she had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix.,social history: , the patient is a widow.  she lives alone.  she does have three daughters, two of them live in georgia and one lives in tennessee.  she did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago.  she never drank any alcohol.  she likes to drink one or two cups of tea in a day.,allergies: , paxil.,medications:,  her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide.,review of systems:,  appetite is good.  she sleeps good at night.  she has no headaches and she has mild joint pains from arthritis.,physical examination:,vital signs:  pulse 90 per minute and regular, blood pressure 140/90 mmhg, respirations 18, and temperature of 98.5 degree fahrenheit.  moderate obesity is present.,cardiac:  carotid upstroke is slightly diminished, but no clear bruit heard.,lungs:  slightly decreased air entry at both bases.  no rales or rhonchi heard.,cardiovascular:  pmi in the left fifth intercostal space in the midclavicular line.  regular heart rhythm.  s1 and s2 normal.  s4 is present.  no s3 heard.  short ejection systolic murmur grade i/vi is present at the left lower sternal border of the apex, peaking in lv systole, no diastolic murmur heard.,abdomen:  soft, obese, no tenderness, no masses felt.  bowel sounds are present.,extremities:  bilateral trace edema.  the extremities are heavy.  there is no pitting at this stage.  no clubbing or cyanosis.  distal pulses are fair.,central nervous system:  without any obvious focal deficits.,laboratory data: , includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block.  this is overall unchanged compared to previous electrocardiogram, which also has the same present.  nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia.  otherwise, laboratory data includes on this patient at this stage wbc 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000.  electrolytes, sodium 137, potassium 5.2, chloride 101, co2 27, bun 34, creatinine 1.2, calcium 9.5, and magnesium 1.7.  ast and alt are normal.  albumin is 4.1.  lipase and amylase are normal.  inr is 0.92.  urinalysis is relatively unremarkable except for trace protein.  chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures.  no infiltrates seen.  abdomen and pelvis cat scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia.  volvulus or adhesions have been considered.  left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis.,impression:,1.  coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.,2.  possible small old myocardial infarction.,3.  hypertension with hypertensive cardiovascular disease.,4.  non-insulin-dependent diabetes mellitus.,5.  moderate obesity.,6.  hyperlipidemia.,7.  chronic non-pitting leg edema.,8.  arthritis.,9.  gerd and positive history of peptic ulcer disease.,conclusion:,1.  past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.,2.  abnormal nuclear stress test in september 2008, but no further cardiac studies performed, such as cardiac catheterization.,3.  lower left quadrant pain, which could be due to diverticulosis.,4.  diverticulosis and partial bowel obstruction.,recommendation:,1.  at this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.",3
"preoperative diagnoses:,1.  chronic pelvic pain.,2.  hypermenorrhea.,3.  desire for future fertility.,4.  failed conservative medical therapy.,postoperative diagnoses:,1.  chronic pelvic pain.,2.  hypermenorrhea.,3.  desire for future fertility.,4.  failed conservative medical therapy.,5.  possible adenomyosis.,6.  left hydrosalpinx.,7.  suspicion for endometriosis.,procedures performed:,1.  dilation and curettage (d&c).,2.  laparoscopy.,3.  harmonic scalpel ablation of lesion which is suspicious for endometriosis.,anesthesia: , general with endotracheal tube.,estimated blood loss: , less than 20 cc.,complications:,  none.,indications: , this is a 35-year-old caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  this patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  symptoms have not improved with prescription of oral contraceptives.,the patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  the cyst was not diagnosed as an endometrioma.  the patient does desire future fertility; however, would like a definitive diagnosis.  conservative medical therapy was offered i.e.  lupron or repeat oral contraceptives, but declined.,findings:,  bimanual exam reveals a small retroverted uterus which is easily mobile.  there were no adnexal masses.  the cervix was normal on palpation.  a fibrotic band was noted at the internal os during dilation.  on laparoscopic exam, the uterus was found to be small with mild spongy texture.  on palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  the left ovary was grossly normal.  the left fallopian tube had a mild hydrosalpinx present.  the left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  the vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  the liver appeared grossly normal.  there were no obvious pelvic adhesions.  the left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,procedure:  ,the patient was seen in the preop suite.  history was reviewed and all questions were answered.  the patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  she was placed in a dorsal lithotomy position in allen stirrups.  she was prepped and draped in the normal sterile fashion.  her bladder was drained with a red robinson catheter producing approximately 100 cc of clear yellow urine.  a bimanual exam was performed by dr. x, dr. y, and dr. z with above findings noted.  a sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  there was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  a #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  an infraumbilical incision was made using skin scalpel.  the veress needle was placed and co2 was insufflated.  it was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the co2 was discontinued and veress needle was completely removed.  a second attempt placement of the veress needle into the abdomen was successful and co2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  the #12 port was placed and the laparoscope was inserted.  attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  the cervix was serially dilated using hank dilators to allow for introduction of the sharp curette.  a curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  this procedure was performed under direct laparoscopic visualization.  laparoscopic evaluation of the pelvis was performed and the above findings noted.  a second abdominal incision was performed suprapubically using a skin scalpel and the veress needle was placed through the incision successfully under direct visualization.  a #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  the manipulator was then removed and the harmonic scalpel was placed through the #5 port.  the harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  the lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  there was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  the harmonic scalpel was removed from the abdomen as was the #5 port.  the incision was internally found to be hemostatic.  the laparoscope was then removed from the abdomen.  the abdomen was desufflated.  the introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  the uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  the weighted speculum was then removed.  the patient taken out of dorsal lithotomy position.  she was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  the patient's discharge instructions will include a followup in one to two weeks in dr. x's office for discussion of pathology.  her family was notified of the findings.  she will be instructed not to have intercourse or use tampons or douche for the next two weeks.  the patient will be sent home with a prescription for darvocet for pain.",37
"general evaluation: ,(twin a),fetal cardiac activity: normal at 166 bpm,fetal lie: twin a lies to the maternal left.,fetal presentation: cephalic,placenta: posterior fused placenta grade i-ii,uterus: normal,cervix: closed,adnexa: not seen,amniotic fluid: there is a single 3.9cm anterior pocket.,biometry:,bpd: 8.7cm consistent with 35 weeks, 1 day,hc: 30.3cm consistent with 33 weeks, 5 days.,ac: 28.2cm consistent with 32 weeks, 1 day,fl:",32
"reason for visit: , followup left-sided rotator cuff tear and cervical spinal stenosis.,history of present illness: , ms. abc returns today for followup regarding her left shoulder pain and left upper extremity c6 radiculopathy.  i had last seen her on 06/21/07.,at that time, she had been referred to me dr. x and dr. y for evaluation of her left-sided c6 radiculopathy.  she also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, i believe on, approximately 07/20/07.  at our last visit, i only had a report of her prior cervical spine mri.  i did not have any recent images.  i referred her for cervical spine mri and she returns today.,she states that her symptoms are unchanged.  she continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with dr. y.,she also has a second component of pain, which radiates down the left arm in a c6 distribution to the level of the wrist.  she has some associated minimal weakness described in detail in our prior office note.  no significant right upper extremity symptoms.  no bowel, bladder dysfunction.  no difficulty with ambulation.,findings: , on examination, she has 4 plus over 5 strength in the left biceps and triceps muscle groups, 4 out of 5 left deltoid, 5 out of 5 otherwise in both muscle groups and all muscle groups of upper extremities.  light touch sensation is minimally decreased in the left c6 distribution; otherwise, intact.  biceps and brachioradialis reflexes are 1 plus.  hoffmann sign normal bilaterally.  motor strength is 5 out of 5 in all muscle groups in lower extremities.  hawkins and neer impingement signs are positive at the left shoulder.,an emg study performed on 06/08/07 demonstrates no evidence of radiculopathy or plexopathy or nerve entrapment to the left upper extremity.,cervical spine mri dated 06/28/07 is reviewed.  it is relatively limited study due to artifact.  he does demonstrate evidence of minimal-to-moderate stenosis at the c5-c6 level but without evidence of cord impingement or cord signal change.  there appears to be left paracentral disc herniation at the c5-c6 level, although axial t2-weighted images are quite limited.,assessment and plan: , ms. abc's history, physical examination and radiographic findings are compatible with left shoulder pain and left upper extremity pain, which is due to a combination of left-sided rotator cuff tear and moderate cervical spinal stenosis.,i agree with the plan to go ahead and continue with rotator cuff surgery.  with regard to the radiculopathy, i believe this can be treated non-operatively to begin with.  i am referring her for consideration of cervical epidural steroid injections.  the improvement in her pain may help her recover better from the shoulder surgery.,i will see her back in followup in 3 months, at which time she will be recovering from a shoulder surgery and we will see if she needs any further intervention with regard to the cervical spine.,i will also be in touch with dr. y to let him know this information prior to the surgery in several weeks.",26
"preoperative diagnosis,1.  carpal tunnel syndrome.,2. de quervain's stenosing tenosynovitis.,postoperative diagnosis,1.  carpal tunnel syndrome.,2. de quervain's stenosing tenosynovitis.,title of procedure,1.  carpal tunnel release.,2. de quervain's release.,anesthesia: , mac,complications: , none.,procedure in detail:  ,after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  the arm was exsanguinated with esmarch and the tourniquet inflated to 250 mmhg.,a longitudinal incision was made in line with the 4th ray, from kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  the dissection was carried down to the superficial aponeurosis.  the subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,the ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  the hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  the antebrachial fascia was cut proximally under direct vision with scissors.,after irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 vicryl.  care was taken to avoid entrapping the motor branch of the median nerve in the suture.  a hemostat was placed under the repair to ensure that the median nerve was not compressed.  the skin was repaired with 5-0 nylon interrupted stitches.,the first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  i released the compartment in a separate subsheath for the epb on the dorsal side.  both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 vicryl.  it was checked to make sure that there was significant room remaining for the tendons.  this was done to prevent postoperative subluxation.,i then irrigated and closed the wounds in layers.  marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  the patient was sent to the recovery room in good condition, having tolerated the procedure well.",37
"exam: , ct chest with contrast.,history: , abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,technique:  ,post contrast-enhanced spiral images were obtained through the chest.,findings:  ,there are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  the remainder of the lung parenchyma is clear.  there is no pneumothorax or effusion.  the heart size and pulmonary vessels appear unremarkable.  there was no axillary, hilar or mediastinal lymphadenopathy.,images of the upper abdomen are unremarkable.,osseous windows are without acute pathology.,impression: , several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.",32
"preoperative diagnoses:,1.  abnormal uterine bleeding.,2.  enlarged fibroid uterus.,3.  hypermenorrhea.,4.  intermenstrual spotting.,5.  thickened endometrium per ultrasound of a 2 cm lining.,postoperative diagnoses:,1.  abnormal uterine bleeding.,2.  enlarged fibroid uterus.,3.  hypermenorrhea.,4.  intermenstrual spotting.,5.  thickened endometrium per ultrasound of a 2 cm lining.,6.  grade 1+ rectocele.,procedure performed:  ,d&c and hysteroscopy.,complications: , none.,history: , the patient is a 48-year-old para 2, vaginal delivery.  she has heavy periods lasting 7 to 14 days with spotting in between her periods.  the patient's uterus is 12.2 x 6.2 x 5.3 cm.  her endometrial thickness is 2 cm.  her adnexa is within normal limits.  the patient and i had a long discussion.  consent was reviewed in layman's terms.  the patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  questions were answered.  the patient was taken back to the operative suite.  the patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  the patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  the patient's history is that she is at risk for development of condyloma.  the patient's husband was found to have a laryngeal papillomatosis.  she has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  her uterus appears to be mobile by 12-week size.  there is a good descend.  there appears to be no adnexal abnormalities.  uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  the patient's cervix was dilated without difficulty utilizing circon acmi hysteroscope with a 12-degree lens.  the patient underwent hysteroscopy.  the outflow valve was opened at all times.  the inflow valve was opened just to achieve appropriate distension.  the patient did have no evidence of trauma of the cervix.  no trendelenburg as we were in room #9.  the patient also had the bag held two fingerbreadths above the level of the heart.  the patient was seen.  there is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  the patient also has one in the fundal area.  the thickened tissue was removed via sharp curettage.  therefore, we reinserted the hysteroscope.  it appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  the patient's procedure was ended with specimen being obtained and sent to department of pathology.  we will follow her up in the office.",23
"medications:,  none.,description of the procedure:,  after informed consent was obtained, the patient was placed in the left lateral decubitus position and the olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  the mucosa appeared normal.  retroflex examination of the rectum was normal.",37
"s:,  xyz is in today not feeling well for the last three days.  she is a bit sick with bodyaches.  she is coughing.  she has a sore throat, especially when she coughs.  her cough is productive of green colored sputum.  she has had some chills.  no vomiting.  no diarrhea.  she is sleeping okay.  she does not feel like she needs anything for the cough.  she did call in yesterday, and got a refill of her keflex.  she took two keflex this morning and she is feeling a little bit better now.  she is tearful, just tired of feeling ran down.,o:,  vital signs as per chart.  respirations 15.  exam:  nontoxic.  no acute distress.  alert and oriented.  heent:  tms are clear bilaterally without erythema or bulging.  clear external canals.  clear tympanic.  conjunctivae are clear.  clear nasal mucosa.  clear oropharynx with moist mucous membranes.  neck is soft and supple without lymphadenopathy.  lungs are coarse with no severe rhonchi or wheezes.  heart is regular rate and rhythm without murmur.  abdomen is soft and nontender.,chest x-ray reveals no obvious consolidation or infiltrates.  we will send the x-ray for over-read.,influenza test is negative.  rapid strep screen is negative.,a:,  bronchitis/uri.,p: , ,1.  motrin as needed for fever and discomfort.,2.  push fluids.,3.  continue on the keflex.,4.  follow up with dr. abc if symptoms persist or worsen, otherwise as needed.",15
"preoperative diagnosis: , lipodystrophy of the abdomen and thighs.,postoperative diagnosis:,  lipodystrophy of the abdomen and thighs.,operation: , suction-assisted lipectomy.,anesthesia:,  general.,findings and procedure:,  with the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  after this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  through these small incisions, a cannula was used to infiltrate lactated ringers with 1000 cc was infiltrated initially into the abdomen.  a 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  attention was then directed to the thighs both inner and outer.  a total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  after this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  the patient tolerated the procedure very well.  all of this aspirate was mostly fat with little fluid and very little blood.  wounds were cleaned and steri-stripped and dressing of abd pads and ***** was then applied.  the patient tolerated the procedure very well and was sent to the recovery room in good condition.",37
"history: , the patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  the patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  the patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  the patient is exclusively breast fed and feeding approximately 2 hours.  upon arrival at children's hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  the electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor r-wave progression, possible right ventricular hypertrophy.,family history:,  family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,review of systems: , a complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,physical examination:,general:  physical examination that showed a sedated, acyanotic infant who is in no acute distress.,vital signs:  heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,heent:  normocephalic with no bruit detected.  she had symmetric shallow breath sounds clear to auscultation.  she had full symmetrical pulses.,heart:  there is normoactive precordium without a thrill.  there is normal s1, single loud s2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,abdomen:  soft.  liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,x-rays:,  review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  there is a prominent thymus.  an echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  the left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  there is a large inlet ventricular septal defect as pulmonary atresia.  the aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  there was a small vertical ductus as a sole source of pulmonary artery blood flow.  the central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  biventricular function is well maintained.,final impression: , the patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  the saturations are now also adequate on prostaglandin e1.,recommendation: , my recommendation is that the patient be continued on prostaglandin e1.  the patient's case was presented to the cardiothoracic surgical consultant, dr. x.  the patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  a consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  the patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible rastelli procedure.  the current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  these findings and recommendations were reviewed with the parents via a spanish interpreter.",5
"preoperative diagnoses:,1.  torn lateral meniscus, right knee.,2.  chondromalacia of the patella, right knee.,postoperative diagnoses:,1.  torn lateral meniscus, right knee.,2.  chondromalacia of the patella, right knee.,procedure performed:,1.  arthroscopic lateral meniscoplasty.,2.  patellar shaving of the right knee.,anesthesia:  ,general.,complications: , none.,estimated blood loss: , minimal.,total tourniquet time:,  zero.,gross findings: , a complex tear involving the lateral and posterior horns of the lateral meniscus and grade-ii chondromalacia of the patella.,history of present illness: , the patient is a 45-year-old caucasian male presented to the office complaining of right knee pain.  he complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,procedure:  ,after all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  the operative extremity was then confirmed with the operative surgeon, the patient, the department of anesthesia and the nursing staff.,the patient was then transferred to preoperative area to operative suite #2, placed on the operating table in supine position.  department of anesthesia administered general anesthetic to the patient.  all bony prominences were well padded at this time.  the right lower extremity was then properly positioned in a johnson knee holder.  at this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  the right lower extremity was then sterilely prepped and draped in usual sterile fashion.  next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  the cannula and trocar were then inserted through this, putting the patellofemoral joint.  an arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  upon viewing of the patellofemoral joint, there was noted to be grade-ii chondromalacia changes of the patella.  there were no loose bodies noted in the either gutter.  upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  while in this area, attention was directed to establish the inferomedial instrument portal.  this was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  a probe was then inserted through this portal and the meniscus was further probed.  again, there was noted to be no meniscal tear.  the knee was taken through range of motion and there was no chondromalacia.  upon viewing of the femoral notch, there was noted to be intact acl with negative drawer sign.  pcl was also noted to be intact.  upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  it was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  an arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a schlesinger grasper was then used to remove the resected meniscus.  it was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  pictures were taken both pre-meniscal resection and post-meniscal resection.  the arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  the lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  next, attention was directed to the inner surface of the patella.  this was debrided using the 2.5 arthroscopic shaver.  it was noted to be quite smooth and postprocedure the patient was taken ________ well.  the knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% marcaine was then administered to each portal as well as intra-articularly.,sterile dressing was then applied consisting of adaptic, 4x4s, abds, and sterile webril and a stockinette to the right lower extremity.  at this time, department of anesthesia reversed the anesthetic.  the patient was transferred back to the hospital gurney to the postanesthesia care unit.  the patient tolerated the procedure and there were no complications.",26
"cc: ,falling to left.,hx:, 26y/orhf fell and struck her head on the ice 3.5 weeks prior to presentation. there was no associated loss of consciousness. she noted a dull headache and severe sharp pain behind her left ear 8 days ago. the pain lasted 1-2 minutes in duration. the next morning she experienced difficulty walking and consistently fell to the left. in addition the left side of her face had become numb and she began choking on food. family noted her pupils had become unequal in size. she was seen locally and felt to be depressed and admitted to a psychiatric facility. she was subsequently transferred to uihc following evaluation by a local ophthalmologist.,meds:, prozac and ativan (both recently started at the psychiatric facility).,pmh: ,1) right esotropia and hyperopia since age 1year. 2) recurrent uti.,fhx:, unremarkable.,shx:, divorced. lives with children. no spontaneous abortions. denied etoh/tobacco/illicit drug use.,exam:, bp 138/110.  hr 85.  rr 16.  temp 37.2c.,ms: a&o to person, place, time. speech fluent and without dysarthria. intact naming, comprehension, repetition.,cn: pupils 4/2 decreasing to 3/1 on exposure to light. optic disks flat. vfftc. esotropia od, otherwise eom full. horizontal nystagmus on leftward gaze. decreased corneal reflex, os. decreased pp/temp sensation on left side of face. light touch testing normal. decreased gag response on left. uvula deviates to right. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: decreased pp and temp on right side of body. prop/vib intact.,coord: difficulty with fnf/hks/ram on left. normal on right side.,station: no pronator drift. romberg test not noted.,gait: unsteady with tendency to fall to left.,reflexes: 3/3 throughout bue and patellae. 2+/2+ achilles. plantar responses were flexor, bilaterally.,gen exam: obese. in no acute distress. otherwise unremarkable.,heent: no carotid/vertebral/cranial bruits.,course:, pt/ptt, gs, cbc, tsh, ft4 and cholesterol screen were all within normal limits. hct on admission was negative. mri brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. the patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at c2 and extending to and involving the basilar artery. there is severe, irregular narrowing of the horizontal portion above the posterior arch of c1. the findings were felt consistent with a left vertebral artery dissection. neuro-opthalmology confirmed a left horner's pupil by clinical exam and history. cookie swallow study was unremarkable. the patient was placed on heparin then converted to coumadin. the pt on discharge was 17.,she remained on coumadin for 3 months and then was switched to asa for 1 year. an otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. a prosthesis was made and no surgical invention was done.",21
"diagnoses:,1.  juvenile myoclonic epilepsy.,2.  recent generalized tonic-clonic seizure.,medications:,1.  lamictal 250 mg b.i.d.,2.  depo-provera.,interim history: , the patient returns for followup.  since last consultation she has tolerated lamictal well, but she has had a recurrence of her myoclonic jerking.  she has not had a generalized seizure.  she is very concerned that this will occur.  most of the myoclonus is in the mornings.  recent eeg did show polyspike and slow wave complexes bilaterally, more prominent on the left.  she states that she has been very compliant with the medications and is getting a good amount of sleep.  she continues to drive.,social history and review of systems are discussed above and documented on the chart.,physical examination: , vital signs are normal.  pupils are equal and reactive to light.  extraocular movements are intact.  there is no nystagmus.  visual fields are full.  demeanor is normal.  facial sensation and symmetry is normal.  no myoclonic jerks noted during this examination.  no myoclonic jerks provoked by tapping on her upper extremity muscles.  negative orbit.  deep tendon reflexes are 2 and symmetric.  gait is normal.  tandem gait is normal.  romberg negative.,impression and plan:,  recurrence of early morning myoclonus despite high levels of lamictal.  she is tolerating the medication well and has not had a generalized tonic-clonic seizure.  she is concerned that this is a precursor for another generalized seizure.  she states that she is compliant with her medications and has had a normal sleep-wake cycle.,looking back through her notes, she initially responded very well to keppra, but did have a breakthrough seizure on keppra.  this was thought secondary to severe insomnia when her baby was very young.  because she tolerated the medication well and it was at least partially affective, i have recommended adding keppra 500 mg b.i.d.  side effect profile of this medication was discussed with the patient.,i will see in followup in three months.",24
"preoperative diagnosis:  ,right trigger thumb.,postoperative diagnosis:,  right trigger thumb.,operations performed:,  trigger thumb release.,anesthesia:,  monitored anesthesia care with regional anesthesia applied by surgeon with local.,complications:,",37
"preoperative diagnoses:,1.  hallux abductovalgus, right foot.,2.  hammertoe, bilateral third, fourth, and fifth toes.,postoperative diagnoses:,1.  hallux abductovalgus, right foot.,2.  hammertoe, bilateral third, fourth, and fifth toes.,procedure performed:,1.  bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2.  proximal interphalangeal joint arthroplasty, bilateral fifth toes.,3.  distal interphalangeal joint arthroplasty, bilateral third and fourth toes.,4.  flexor tenotomy, bilateral third toes.,history:,  this is a 36-year-old female who presented to abcd preoperative holding area after keeping herself n.p.o. since mid night for surgery on her painful bunion to her right foot and her painful hammertoes to both feet.  the patient has a history of sharp pain, which is aggravated by wearing shoes and ambulation.  she has tried multiple conservative methods and treatment such as wide shoes and accommodative padding, all of which provided inadequate relief.  at this time, she desires attempted surgical correction.  the risks versus benefits of the procedure have been discussed in detail by dr. kaczander with the patient and the consent is available on the chart.,procedure in detail:,  after iv was established by the department of anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with a safety strap placed across her waist for her protection.,copious amounts of webril were applied about both ankles and a pneumatic ankle tourniquet was applied over the webril.  after adequate iv sedation was administered, a total of 18 cc of a 0.5% marcaine plain was used to anesthetize the right foot, performing a mayo block and a bilateral third, fourth, and fifth digital block.  next, the foot was prepped and draped in the usual aseptic fashion bilaterally.  the foot was elevated off the table and an esmarch bandage was used to exsanguinate the right foot.  the pneumatic ankle tourniquet was elevated on the right foot to 200 mmhg.  the foot was lowered into operative field and the sterile stockinet was reflected proximally.  attention was directed to the right first metatarsophalangeal joint, it was found to be contracted and there was lateral deviation of the hallux.  there was decreased range of motion of the first metatarsophalangeal joint.  a dorsolinear incision was made with a #10 blade, approximately 4 cm in length.  the incision was deepened to the subcutaneous layer with a #15 blade.  any small veins traversing the subcutaneous layer were ligated with electrocautery.  next, the medial and lateral wound margins were undermined sharply.  care was taken to avoid the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  next, the first metatarsal joint capsule was identified.  a #15 blade was used to make a linear capsular incision down to the bone.  the capsular periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  the pasa was found to be within normal limits.  there was a hypertrophic medial eminence noted.  a sagittal saw was used to remove the hypertrophic medial eminence.  a 0.045 inch kirschner wire was placed into the central medial aspect of the metatarsal head as an access guide.  a standard lateral release was performed.  the fibular sesamoid was found to be in the interspace, but was relocated onto the metatarsal head properly.  next, a sagittal saw was used to perform a long arm austin osteotomy.  the k-wire was removed.  the capital fragment was shifted laterally and impacted into the head.  a 0.045 inch kirschner wire was used to temporarily fixate the osteotomy.  a 2.7 x 16 mm synthes, fully threaded cortical screw was throne using standard ao technique.  a second screw was throne, which was a 2.0 x 12 mm synthes cortical screw.  excellent fixation was achieved and the screws tightly perched the bone.  next, the medial overhanging wedge was removed with a sagittal saw.  a reciprocating rasp was used to smooth all bony prominences.  the 0.045 inch kirschner wire was removed.  the screws were checked again for tightness and found to be very tight.  the joint was flushed with copious amounts of sterile saline.  a #3-0 vicryl was used to close the capsular periosteal tissues with simple interrupted suture technique.  a #4-0 vicryl was used to close the subcutaneous layer in a simple interrupted technique.  a #5-0 monocryl was used to close the skin in a running subcuticular fashion.,attention was directed to the right third digit, which was found to be markedly contracted at the distal interphalangeal joint.  a #15 blade was used to make two convergent semi-elliptical incisions over the distal interphalangeal joint.  the incision was deepened with a #15 blade.  the wedge of skin was removed in full thickness.  the long extensor tendon was identified and the distal and proximal borders of the wound were undermined.  the #15 blade was used to transect the long extensor tendon, which was reflected proximally.  the distal interphalangeal joint was identified and the #15 blade was placed in the joint and the medial and lateral collateral ligaments were released.  crown and collar scissors were used to release the planar attachment to the head of the middle phalanx.  next, a double action bone cutter was used to resect the head of the middle phalanx.  the toe was dorsiflexed and was found to have an excellent rectus position.  a hand rasp was used to smooth all bony surfaces.  the joint was flushed with copious amounts of sterile saline.  the flexor tendon was found to be contracted, therefore, a flexor tenotomy was performed through the dorsal incision.  next, #3-0 vicryl was used to close the long extensor tendon with two simple interrupted sutures.  a #4-0 nylon was used to close the skin and excellent cosmetic result was achieved.,attention was directed to the fourth toe, which was found to be contracted at the distal interphalangeal joint and abducted and varus rotated.  an oblique skin incision with two converging semi-elliptical incisions was created using #15 blade.  the rest of the procedure was repeated exactly the same as the above paragraph to the third toe on the right foot.  all the same suture materials were used.  however, there was no flexor tenotomy performed on this toe, only on the third toe bilaterally.,attention was directed to the fifth right digit, which was found to be contracted at the proximal interphalangeal joint.  a linear incision approximately 2 cm in length was made with a #15 blade over the proximal interphalangeal joint.  next, a #15 blade was used to deepen the incision to the subcutaneous layer.  the medial and lateral margins were undermined sharply to the level of the long extensor tendon.  the proximal interphalangeal joint was identified and the tendon was transected with the #15 blade.  the tendon was reflected proximally, off the head of the proximal phalanx.  the medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  a double action bone nibbler was used to remove the head of the proximal phalanx.  a hand rasp was used to smooth residual bone.  the joint was flushed with copious amounts of saline.  a #3-0 vicryl was used to close the long extensor tendon with two simple interrupted sutures.  a #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress sutures.,a standard postoperative dressing consisting of saline-soaked #0-1 silk, 4 x 4s, kerlix, kling, and coban were applied.  the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,attention was directed to the left foot.  the foot was elevated off the table and exsanguinated with an esmarch bandage and the pneumatic ankle tourniquet was elevated to 200 mmhg.  attention was directed to the left fifth toe, which was found to be contracted at the proximal interphalangeal joint.  the exact same procedure, performed to the right fifth digit, was performed on this toe, with the same materials being used for suture and closure.,attention was then directed to the left fourth digit, which was found to contracted and slightly abducted and varus rotated.  the exact same procedure as performed to the right fourth toe was performed, consisting of two semi-elliptical skin incisions in an oblique angle.  the same suture material were used to close the incision.,attention was directed to the left third digit, which was found to be contracted at the distal interphalangeal joint.  the same procedure performed on the right third digit was also performed.  the same suture materials were used to close the wound and the flexor tenotomy was also performed at this digit.  a standard postoperative dressing was also applied to the left foot consisting of the same materials as described for the right foot.  the pneumatic tourniquet was released and immediate hyperemic flush was noted to the digits.  the patient tolerated the above anesthesia and procedure without complications.  she was transported via cart to the postanesthesia care unit with vital signs stable and vascular status intact to the foot.  she was given postoperative shoes and will be partial weighbearing with crutches.  she was admitted short-stay to dr. kaczander for pain control.  she was placed on demerol 50 and vistaril 25 mg im q3-4h. p.r.n. for pain.  she will have vicodin 5/500 one to two p.o. q.4-6h. p.r.n. for moderate pain.  she was placed on subq. heparin and given incentive spirometry 10 times an hour.  she will be discharged tomorrow.  she is to ice and elevate both feet today and rest as much as possible.,physical therapy will teach her crutch training today.  x-rays were taken in the postoperative area and revealed excellent position of the screws and correction of bunion deformity as well as the hammertoe deformities.",26
"ct head without contrast, ct facial bones without contrast, and ct cervical spine without contrast,reason for exam: , motor vehicle collision.,ct head,technique: , noncontrast axial ct images of the head were obtained without contrast.,findings: , there is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  the ventricles and cortical sulci are normal in shape and configuration.  the gray/white matter junctions are well preserved.  no calvarial fracture is seen.,impression:  ,negative for acute intracranial disease.,ct facial bones without contrast,technique:  ,noncontrast axial ct images of the facial bones were obtained with coronal reconstructions.,findings:,  there is no facial bone fracture.  the maxilla and mandible are intact.  the visualized paranasal sinuses are clear.  the temporomandibular joints are intact.  the nasal bone is intact.  the orbits are intact.  the extra-ocular muscles and orbital nerves are normal.  the orbital globes are normal.,impression: , no evidence for a facial bone fracture.,ct cervical spine without contrast,technique: , noncontrast axial ct images of the cervical spine were obtained with sagittal and coronal reconstructions.,findings: , there is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  the vertebral body heights are normal.  the intervertebral disk spaces are well preserved.  the atlanto-dens interval is normal.  no abnormal anterior cervical soft tissue swelling is seen.  there is no spinal compression deformity.,impression: , negative for a facial bone fracture.",20
"general:  ,xxx,vital signs: , blood pressure xxx, pulse xxx, temperature xxx, respirations xxx.  height xxx, weight xxx.,head: , normocephalic.  negative lesions, negative masses.,eyes: , perla, eomi.  sclerae clear.  negative icterus, negative conjunctivitis.,ent:,  negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  negative ear obstructions, negative exudates.  negative inflammation in external auditory canals.  negative throat inflammation or masses.,skin: , negative rashes, negative masses, negative ulcers.  no tattoos.,neck:,  negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,heart:,  regular rate and rhythm.  negative rubs, negative gallops, negative murmurs.,lungs:,  clear to auscultation.  negative rales, negative rhonchi, negative wheezing.,abdomen: , soft, nontender, adequate bowel sounds.  negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,extremities: , negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  pulses adequate bilaterally.,musculoskeletal:,  negative muscle atrophy, negative masses.  strength adequate bilaterally.  negative movement restriction, negative joint crepitus, negative deformity.,neurologic: , cranial nerves i through xii intact.  negative gait disturbance.  balance and coordination intact.  negative romberg, negative babinski.  dtrs equal bilaterally.,genitourinary:  ,deferred.,",24
"diagnosis at admission: , congestive heart failure (chf) with left pleural effusion.,diagnoses at discharge,1.  congestive heart failure (chf) with pleural effusion.,2.  hypertension.,3.  prostate cancer.,4.  leukocytosis.,5. anemia of chronic disease.,hospital course:  ,the patient was admitted to the emergency room by dr. x. he has diuresed with iv lasix.  he was placed on prinivil, aspirin, oxybutynin, docusate, and klor-con.  chest x-rays were followed.  he did have free flowing fluid in his left chest.  radiology consultation was obtained for thoracentesis.  the patient was seen by dr. y. an echocardiogram was done.  this revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3.  an adenosine sestamibi was done in march 2000, with a small fixed apical defect, but no ischemia.  cardiac enzymes were negative.  dr. y recommended a beta-blocker with an ace inhibitor; therefore, the lisinopril was discontinued.  the patient felt much better after the thoracentesis.  i do not have the details of this, i.e., the volumes.  no fluid was sent for routine studies.,laboratory at discharge: , sodium 134, potassium 4.2, chloride 99, co2 26, glucose 182, bun 17, and creatinine 1.0.  glucose was elevated because of several doses of solu-medrol given to him because of bronchospams.  magnesium was 1.8, calcium was 8.1.  liver enzymes were unremarkable.  cardiac enzymes were normal as mentioned.  pt/inr is 1.02, ptt 31.3, white blood cell count 15, 000 with a left shift.  this was presumed due to the corticosteroids.  h&h was 32.3/11.3 and platelets 352,000, and mcv was 99.  the patient's o2 saturations on room air were normal.,vital signs were stable.,discharge medications: , he is being discharged home on lasix 40 mg daily, potassium chloride 10 meq daily, atenolol 25 mg daily, aspirin 5 grains daily, ditropan 5 mg b.i.d., and colace 100 mg b.i.d.,followup: , he will be followed in my office in 1 week.  he is to notify if recurrent fever or chills.,prognosis:  ,guarded.",10
"problem:,  probable coumadin hypersensitivity.,history of present illness:,  the patient is an 82-year-old caucasian female admitted to the hospital for elective total left knee arthroplasty.  at the time of admission, the patient has a normal prothrombin time and inr of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  however, the patient's prothrombin time and inr rapidly rose to supratherapeutic levels.  even though coumadin was discontinued on 01/21/09, the patient's prothrombin time and inr has continued to rise.  her prothrombin time is now 83.3 seconds with an inr of 6.52.  hematology/oncology consult was requested for recommendation regarding further evaluation and management.,social history: , the patient is originally from maine.  she has lived in arizona for 4 years.  she has had 2 children; however, only one is living.  she had one child died from complications of ulcerative colitis.  she has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,childhood history: , negative for rheumatic fever.  the patient has usual childhood illnesses.,allergies:  ,no known drug allergies.,family history: , the patient's mother died from gastric cancer.  she had a brother who died from mesothelioma.  he did have a positive asbestos exposure working in the shipyards.  the patient's father died from motor vehicle accident.  she had a sister who succumbed to pneumonia as a complication to alzheimer disease.,habits: , no use of ethanol, tobacco, illicit, or recreational substances.,adult medical problems: , the patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome x.  in addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,surgeries: , the patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,medications: , the patient's medications on admission include:,1.  fosamax.,2.  tricor.,3.  gabapentin.,4.  hydrochlorothiazide.,5.  labetalol.,6.  benicar.,7.  crestor.,8.  detrol.,review of systems: , unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  she is arousable, but not particularly conversant.,observations:,general:  the patient is a drowsy, but arousable, nonconversant, elderly caucasian female.,heent:  pupils were equal, round, and reactive to light and accommodation.  extraocular muscles are grossly intact.  oropharynx benign.,neck:  supple.  full range of motion without bruits or thyromegaly.,lungs:  clear to auscultation and percussion.,back:  without spine or cva tenderness.,heart:  regular rate and rhythm without murmurs, rubs, thrills, or heaves.,abdomen:  soft and nontender.  positive bowel sounds without mass or visceromegaly.,lymphatic:  no appreciable adenopathy.,extremities:  the patient has some postoperative fullness involving her left knee.  she has a dressing over the left knee.,skin:  without lesions.,neuro:  unable to assess in light of post morphine obtunded state.,assessment: , hypersensitivity to coumadin.,plan: , gave the patient vitamin k at this time.  literature suggested oral vitamin k is actually more efficacious than parenteral.  however, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an im fashion.  repeat prothrombin time and inr in a.m.  once she has come down to a more therapeutic range, i would initiate low-molecular weight heparin in the form of fragmin one time a day or lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively.",15
"preoperative diagnosis: , bilateral progressive conductive hearing losses with probable otosclerosis.,postoperative diagnosis: , bilateral conductive hearing losses with right stapedial fixation secondary to otosclerosis.,operation performed: , right argon laser assisted stapedectomy.,description of operation:  ,the patient was brought to the operating room.  endotracheal intubation carried out by dr. x. the patient's right ear was carefully prepped and then draped in the usual sterile fashion.  slow infiltration of the external canal accomplished with 1% xylocaine with epinephrine.  the earlobe was also infiltrated with the same solution.  a limited incision was made in the earlobe harvesting a small bit of fat from the earlobe that was diced and the donor site closed with interrupted sutures of 5-0 nylon.  this could later be removed in bishop.  a reinspection of the ear canal was accomplished.  a 65 beaver blade was used to make incision both at 12 o'clock and at 6 o'clock.  jordan round knife was used to incise the tympanomeatal flap with an adequate cuff for later reapproximation.  elevation was carried down to the fibrous annulus.  an annulus elevator was used to complete the elevation beneath the annular ligament.  the tympanic membrane and the associated flap rotated anteriorly exposing the ossicular chain.  palpation of the malleus revealed good mobility of both it and incus, but no movement of the stapes was identified.  palpation with a fine curved needle on the stapes itself revealed no movement.  a house curette was used to takedown portions of the scutum with extreme care to avoid any inadvertent trauma to the chorda tympani.  the nerve was later hydrated with a small curved needle and an additional fluid to try to avoid inadvertent desiccation of it as well.  the self-retaining speculum holder was used to get secure visibility and argon laser then used to create rosette on the posterior cruse.  the stapes superstructure anteriorly was mobilized with a right angle hook at the incostapedial joint and the superstructure could then be downfractured.  the fenestration created in the footplate was nearly perfect for placement of the piston and therefore additional laser vaporization was not required in this particular situation.  a small bit of additional footplate was removed with a right angle hook to accommodate the 0.6 mm piston.  the measuring device was used and a 4.25 mm slim shaft wire teflon piston chosen.  it was placed in the middle ear atraumatically with a small alligator forceps and was directed towards the fenestration in the footplate.  the hook was placed over the incus and measurement appeared to be appropriate.  a downbiting crimper was then used to complete the attachment of the prosthesis to the incus.  prosthesis is once again checked for location and centering and appeared to be in ideal position.  small pledgets of fat were placed around the perimeter of the piston in an attempt to avoid any postoperative drainage of perilymph.  a small pledget of fat was also placed on the top of the incudo-prosthesis junction.  the mobility appeared excellent.  the flap was placed back in its normal anatomic position.  the external canal packed with small pledgets of gelfoam and antibiotic ointment.  she was then awakened and taken to the recovery room in a stable condition with discharge anticipated later this day to bishop.  sutures will be out in a week and a recheck in reno in four to five weeks from now.",37
"delivery note: , the patient is a very pleasant 22-year-old primigravida with prenatal care with both dr. x and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  the patient was admitted to labor and delivery on tuesday, december 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  her cervix on admission was not ripe, so she was given a dose of cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  at a later time, pitocin was started.  the next day at about 9 o'clock in the morning, i checked her cervix and performed artifical rupture of membranes, which did reveal meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then mdl infusion started.  the patient did have labor epidural, which worked well.  it should be noted that the patient's recent vaginal culture for group b strep did come back negative for group b strep.  the patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  the intensive care nursery staff was present because of the presence of meconium-stained amniotic fluid.  delee suctioning was performed at the perineum.  a second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 vicryl.  the placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,estimated blood loss: , approximately 300 ml.",23
"history: , a 34-year-old male presents today self-referred at the recommendation of emergency room physicians and his nephrologist to pursue further allergy evaluation and treatment.  please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at abc medical center for further details and studies.  in summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from abc medical center to xyz medical center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  in summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  he currently is not taking any medication for allergies.  he is taking atenolol for blood pressure control.  no further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,past medical history:,  history of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,past surgical history:,  permcath insertion times 3 and peritoneal dialysis.,family history: , strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,current medications: , atenolol, sodium bicarbonate, lovaza, and dialyvite.,allergies: , heparin causing thrombocytopenia.,social history: , denies tobacco or alcohol use.,physical examination:  ,vital signs:  age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,general:  the patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,head:  normocephalic.  no masses or lesions noted.,face:  no facial tenderness or asymmetry noted.,eyes:  pupils are equal, round and reactive to light and accommodation bilaterally.  extraocular movements are intact bilaterally.,ears:  the tympanic membranes are intact bilaterally with a good light reflex.  the external auditory canals are clear with no lesions or masses noted.  weber and rinne tests are within normal limits.,nose:  the nasal cavities are patent bilaterally.  the nasal septum is midline.  there are no nasal discharges.  no masses or lesions noted.,throat:  the oral mucosa appears healthy.  dental hygiene is maintained well.  no oropharyngeal masses or lesions noted.  no postnasal drip noted.,neck:  the neck is supple with no adenopathy or masses palpated.  the trachea is midline.  the thyroid gland is of normal size with no nodules.,neurologic:  facial nerve is intact bilaterally.  the remaining cranial nerves are intact without focal deficit.,lungs:  clear to auscultation bilaterally.  no wheeze noted.,heart:  regular rate and rhythm.  no murmur noted.,impression:  ,1.  acute allergic reaction, etiology uncertain, however, suspicious for keflex.,2.  renal failure requiring dialysis.,3.  hypertension.,recommendations:  ,rast allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  if there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  at this point, i would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and i would consider this an allergy.  being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but i do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  an epipen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an epipen.",0
"eyes: , the conjunctivae are clear.  the lids are normal appearing without evidence of chalazion or hordeolum.  the pupils are round and reactive.  the irides are without any obvious lesions noted.  funduscopic examination shows sharp disk margins.  there are no exudates or hemorrhages noted.  the vessels are normal appearing.,ears, nose, mouth and throat:,  the nose is without any evidence of any deformity.  the ears are with normal-appearing pinna.  examination of the canals is normal appearing bilaterally.  there is no drainage or erythema noted.  the tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  hearing is grossly intact to finger rubbing and whisper.  the nasal mucosa is moist.  the septum is midline.  there is no evidence of septal hematoma.  the turbinates are without abnormality.  no obvious abnormalities to the lips.  the teeth are unremarkable.  the gingivae are without any obvious evidence of infection.  the oral mucosa is moist and pink.  there are no obvious masses to the hard or soft palate.  the uvula is midline.  the salivary glands appear unremarkable.  the tongue is midline.  the posterior pharynx is without erythema or exudate.  the tonsils are normal appearing.,neck:,  the neck is nontender and supple.  the trachea is midline.  the thyroid is without any evidence of thyromegaly.  no obvious adenopathy is noted to the neck.,respiratory: , the patient has normal respiratory effort.  there is normal lung excursion.  percussion of the chest is without any obvious dullness.  there is no tactile fremitus or egophony noted.  there is no tenderness to the chest wall or ribs.  there are no obvious abnormalities.  the lungs are clear to auscultation.  there are no wheezes, rales or rhonchi heard.  there are no obvious rubs noted.,cardiovascular: , there is a normal pmi on palpation.  i do not hear any obvious abnormal sounds.  there are no obvious murmurs.  there are no rubs or gallops noted.  the carotid arteries are without bruit.  no obvious thrill is palpated. there is no evidence of enlarged abdominal aorta to palpation.  there is no abdominal mass to suggest enlargement of the aorta.  good strong femoral pulses are palpated.  the pedal pulses are intact.  there is no obvious edema noted to the extremities.  there is no evidence of any varicosities or phlebitis noted.,gastrointestinal: , the abdomen is soft.  bowel sounds are present in all quadrants.  there are no obvious masses.  there is no organomegaly, and no liver or spleen is palpable.  no obvious hernia is noted.  the perineum and anus are normal in appearance.  there is good sphincter tone and no obvious hemorrhoids are noted.  there are no masses.  on digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  stool is brown and guaiac negative.,genitourinary (female): , the external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  the vagina is normal in appearance with normal-appearing mucosa.  the urethra is without any obvious lesions or discharge.  the cervix is normal in color with no obvious cervical discharge.  there are no obvious cervical lesions noted.  the uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  the bladder is nontender to palpation.  it is not enlarged.,genitourinary (male): , normal scrotal contents are noted.  the testes are descended and nontender.  there are no masses and no swelling to the epididymis noted.  the penis is without any lesions.  there is no urethral discharge.  digital examination of the prostate reveals a nontender, non-nodular prostate.,breasts:,  the breasts are normal in appearance.  there is no puckering noted.  there is no evidence of any nipple discharge.  there are no obvious masses palpable.  there is no axillary adenopathy.  the skin is normal appearing over the breasts.,lymphatics: , there is no evidence of any adenopathy to the anterior cervical chain.  there is no evidence of submandibular nodes noted.  there are no supraclavicular nodes palpable.  the axillae are without any abnormal nodes.  no inguinal adenopathy is palpable.  no obvious epitrochlear nodes are noted.,musculoskeletal/extremities: , the patient has normal gait and station.  the patient has normal muscle strength and tone to all extremities.  there is no obvious evidence of any muscle atrophy.  the joints are all stable.  there is no evidence of any subluxation or laxity to any of the joints.  there is no evidence of any dislocation.  there is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  there is no evidence of any contractures or crepitus.  there is no evidence of any joint effusions.  no obvious evidence of erythema overlying any of the joints is noted.  there is good range of motion at all joints.  there are normal-appearing digits.  there are no obvious lesions to any of the nails or nail beds.,skin:,  there is no obvious evidence of any rash.  there are no petechiae, pallor or cyanosis noted.  there are no unusual nodules or masses palpable.,neurologic: , the cranial nerves ii xii are tested and are intact.  deep tendon reflexes are symmetrical bilaterally.  the toes are downgoing with normal babinskis.  sensation to light touch is intact and symmetrical.  cerebellar testing reveals normal finger nose, heel shin.  normal gait.  no ataxia.,psychiatric:  ,the patient is oriented to person, place and time.  the patient is also oriented to situation.  mood and affect are appropriate for the present situation.  the patient can remember 3 objects after 3 minutes without any difficulties.  remote memory appears to be intact.  the patient seems to have normal judgment and insight into the situation.",15
"exam:,  ct examination of the abdomen and pelvis with intravenous contrast.,indications:,  abdominal pain.,technique:  ,ct examination of the abdomen and pelvis was performed after 100 ml of intravenous isovue-300 contrast administration.  oral contrast was not administered.  there was no comparison of studies.,findings,ct pelvis:,within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  there is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  there is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  several smaller fibroids were also suspected.,the ovaries are unremarkable in appearance.  there is no free pelvic fluid or adenopathy.,ct abdomen:,the appendix has normal appearance in the right lower quadrant.  there are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  the small and large bowels are otherwise unremarkable.  the stomach is grossly unremarkable.  there is no abdominal or retroperitoneal adenopathy.  there are no adrenal masses.  the kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  the spleen contains several small calcified granulomas, but no evidence of masses.  it is normal in size.  the lung bases are clear bilaterally.  the osseous structures are unremarkable other than mild facet degenerative changes at l4-l5 and l5-s1.,impression:,1.  hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  multiple uterine fibroids.,3.  prominent endometrium.,4.  followup pelvic ultrasound is recommended.",32
"preoperative diagnoses:,1.  intrauterine pregnancy at 33 weeks, twin gestation.,2.  active preterm labor.,3.  advanced dilation.,4.  multiparity.,5.  requested sterilization.,postoperative diagnosis:,1.  intrauterine pregnancy at 33 weeks, twin gestation.,2.  active preterm labor.,3.  advanced dilation.,4.  multiparity.,5.  requested sterilization.,6.  delivery of a viable female a weighing 4 pounds 7 ounces, apgars were 8 and 9 at 1 and 5 minutes respectively and female b weighing 4 pounds 9 ounces, apgars 6 and 7 at 1 and 5 minutes respectively.,7.  uterine adhesions and omentum adhesions.,operation performed: , repeat low-transverse c-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,anesthesia: , general.,estimated blood loss: , 500 ml.,drains:,  foley.,this is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous c-section.  the patient presents to labor and delivery in active preterm labor and dilated approximately 4 to 6 cm.  the decision for c-section was made.,procedure:,  the patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  the patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  the fascia was nicked in the center and extended in a transverse fashion with the use of curved mayo scissors.  the edges of the fascia were grasped with kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  the abdominal rectus muscle was divided in the center and extended in a vertical fashion.  peritoneum was entered at a high point and extended in a vertical fashion as well.  the bladder blade was put in place.  the bladder flap was created with the use of metzenbaum scissors and dissected away caudally.  the second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  the first fetus was vertex.  the fluid was clear.  the head was delivered followed by the remaining portion of the body.  the cord was doubly clamped and cut.  the newborn handed off to waiting pediatrician and nursery personnel.  the second fluid was ruptured.  it was the clear fluid as well.  the presenting part was brought down to be vertex.  the head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  cord ph blood and cord blood was obtained from both of the cords with careful identification of a and b. once this was completed, the placenta was delivered and handed off for further inspection by pathology.  at this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  then, there were multiple omental adhesions on the surface of the uterus itself.  this needed to be released as well as on the abdominal wall and then the uterus could be externalized.  the lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  the bladder flap was re-approximated with 3-0 vicryl and gelfoam underneath.  the right fallopian tube was grasped with a babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  the same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  the defect on the uterine surface was reinforced with 0 vicryl in a baseball stitch to create adequate hemostasis.  interceed was placed over this area as well.  the abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  the gutters were wiped clean of any remaining blood.  the edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  the abdominal rectus muscle was irrigated.  the corners of the fascia grasped with hemostats and continuous locking stitch of 0 vicryl started on both corners and overlapped on the center.  the subcutaneous tissue was irrigated.  cautery was used to create adequate hemostasis and 3-0 vicryl was used to re-approximate the subcutaneous tissue.  skin edges were re-approximated with sterile staples.  sterile dressing was applied.  uterus was evacuated of any remaining blood vaginally.  the patient was taken to the recovery room in stable condition.  instrument count, needle count, and sponge counts were all correct.",37
"ct abdomen with contrast and ct pelvis with contrast,reason for exam: , generalized abdominal pain with swelling at the site of the ileostomy.,technique:,  axial ct images of the abdomen and pelvis were obtained utilizing 100 ml of isovue-300.,ct abdomen:  ,the liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  punctate calcifications in the gallbladder lumen likely represent a gallstone.,ct pelvis:  ,postsurgical changes of a left lower quadrant ileostomy are again seen.  there is no evidence for an obstruction.  a partial colectomy and diverting ileostomy is seen within the right lower quadrant.  the previously seen 3.4 cm subcutaneous fluid collection has resolved.  within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  this is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  no obstruction is seen.  the appendix is not clearly visualized.  the urinary bladder is unremarkable.,impression:,1.  resolution of the previously seen subcutaneous fluid collection.,2.  left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  these findings may be due to a pelvic abscess.,3.  right lower quadrant ileostomy has not significantly changed.,4.  cholelithiasis.",20
"procedure performed: , carpal tunnel release.,indications for surgery: , nerve conduction study tests diagnostic of carpal tunnel syndrome.  the patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,procedure:  ,the patient was brought to the operating room and, following a bier block to the operative arm, the arm was prepped and draped in the usual manner.,utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  it was identified at its distal edge.  using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  the canal was probed with a small finger to verify no evidence of any bone prominences.  the nerve was examined for any irregularity.  there was slight hyperemia of the nerve and a slight hourglass deformity.  following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  a sterile dressing was applied.,the patient was taken to the recovery room in satisfactory condition.,the time of the bier block was 30 minutes.,complications: , none noted.",37
"xyz street,city, state,dear dr. cd:,thank you for seeing mr. xyz, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  he comes to my office today continuing on dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  he is requesting to come off the dilantin at this point.  upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  his physical exam, neurologically, is normal at this time.  his dilantin level is slightly low at 12.5.,i will appreciate your evaluation and recommendation as to whether we need to continue the dilantin at this time.  i understand this will probably entail repeating his eeg and so please coordinate this through health center.  i await your response and whether we should continue this medication.  if you require any laboratory, we use abc diagnostic and any further testing that is needed should be coordinated at health center prior to scheduling.",21
"reason for consultation:,  this is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,past medical history: , hypertension.  the patient noncompliant,history of present complaint: , this 66-year-old patient has history of hypertension and has not taken medication for several months.  she is a smoker and she drinks alcohol regularly.  she drinks about 5 glasses of wine every day.  last drink was yesterday evening.  this afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  on arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  the patient received 5 mg of metoprolol iv, after which heart rate was reduced to the 70 and blood pressure was well controlled.  on direct questioning, the patient said she had been drinking a lot.  she had not had any withdrawal before.  today is the first time she has been close to withdrawal.,review of systems:,constitutional:  no fever.,ent:  not remarkable.,respiratory:  no cough or shortness of breath.,cardiovascular:  the patient denies chest pain.,gastrointestinal:  no nausea.  no vomiting.  no history of gi bleed.,genitourinary:  no dysuria.  no hematuria.,endocrine:  negative for diabetes or thyroid problems.,neurologic:  no history of cva or tia.,rest of review of systems is not remarkable.,social history:  ,the patient is a smoker and drinks alcohol daily in considerable amounts.,family history: , noncontributory.,physical examination:,general:  this is a 66-year-old lady with telangiectasia of the face.  she is not anxious at this moment and had no tremors.,chest:  clear to auscultation.  no wheezing.  no crepitations.  chest is tympanitic to percussion.,cardiovascular:  first and second heart sounds were heard.  no murmur was appreciated.,abdomen:  soft and nontender.  bowel sounds are positive.,extremities:  there is no swelling.  no clubbing.  no cyanosis.,neurologic:  the patient is alert and oriented x3.  examination is nonfocal.,diagnostic data: , ekg shows sinus tachycardia, no acute st changes.,laboratory data: , white count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  glucose is 124, bun is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  liver enzymes are within normal limits.  tsh is normal.,assessment and plan:,1.  uncontrolled hypertension.  we will start the patient on beta-blockers.  the patient is to see her primary physician within 1 week's time.,2.  tachycardia, probable mild withdrawal to alcohol.  the patient is stable now.  we will discharge home with diazepam p.r.n.  the patient had been advised that she should not take alcohol if she takes the diazepam.,3.  tobacco smoking disorder.  the patient has been counseled.  she is not contemplating quitting at this time.,disposition: , the patient is discharged home.,discharge medications:,1.  atenolol 50 mg p.o. b.i.d.,2.  diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  thiamine 100 mg p.o. daily.",12
"operation: , subxiphoid pericardial window.,anesthesia: , general endotracheal anesthesia.,operative procedure in detail:  ,after obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  next, the neck and chest were prepped and draped in the standard surgical fashion.  a #10-blade scalpel was used to make an incision in the area of the xiphoid process.  dissection was carried down to the level of the fascia using bovie electrocautery.  the xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free.  next the pericardium was identified.,the pericardium was opened with bovie electrocautery.  upon entering the pericardium, serous fluid was expressed.  in total, ** cc of fluid was drained.  a pericardial biopsy was obtained.  the fluid was sent off for cytologic examination as well as for culture.  a #24 blake chest drain was brought out through the skin and placed in the posterior pericardium.  the fascia was closed with #1 vicryl followed by 2-0 vicryl followed by 4-0 pds in a running subcuticular fashion.  sterile dressing was applied.",37
"grade ii:  atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,grade iii:  atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,grade iv:  the vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,right carotid system: , the common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  the internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  the external carotid artery shows no disease.  the vertebral was present and was antegrade.,left carotid system: , the common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  the external carotid artery shows no disease.  the vertebral was present and was antegrade.,impression:,  bilateral atherosclerotic changes with no evidence for any significant obstructive disease.",3
"reason for return visit: , followup of left hand discomfort and systemic lupus erythematosus.,history of present illness: , the patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right.  the patient was seen on 10/30/07.  she had the same complaint.  she was given a trial of elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy.  she was also given a prescription for zostrix cream but was unable to get it filled because of insurance coverage.  the patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits.  the patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature.  she has not had any night sweats or chills.  she has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with gu or gi complaints.  she is returning today for routine followup evaluation.,current medications:,1.  plaquenil 200 mg twice a day.,2.  fosamax 170 mg once a week.,3.  calcium and vitamin d complex twice daily.,4.  folic acid 1 mg per day.,5.  trilisate 1000 mg a day.,6.  k-dur 20 meq twice a day.,7.  hydrochlorothiazide 15 mg once a day.,8.  lopressor 50 mg one-half tablet twice a day.,9.  trazodone 100 mg at bedtime.,10.  prempro 0.625 mg per day.,11.  aspirin 325 mg once a day.,12.  lipitor 10 mg per day.,13.  pepcid 20 mg twice a day.,14.  reglan 10 mg before meals and at bedtime.,15.  celexa 20 mg per day.,review of systems: , noncontributory except for what was noted in the hpi and the remainder or complete review of systems is unremarkable.,physical examination:,vital signs:  blood pressure 155/84, pulse 87, weight 223 pounds, and temperature 99.2.  general:  she is a well-developed, well-nourished female appearing her staged age.  she is alert, oriented, and cooperative.  heent:  normocephalic and atraumatic.  there is no facial rash.  no oral lesions.  lungs:  clear to auscultation.  cardiovascular:  regular rate and rhythm without murmurs, rubs or gallops.  extremities:  no cyanosis or clubbing.  sensory examination of the upper extremity decreased to light touch on the distal tips of the left second and third digits compared to the fifth digit.  positive tinel sign.  full range of motion of the wrist with no evidence of motor atrophy or muscle loss.,laboratory data:  ,wbc 5100, hemoglobin 11.1, hematocrit 32.8, and platelets 200,000.  westergren sedimentation rate of 47.  urinalysis is negative for protein and blood.  lupus serology is pending.,assessment:,1.  systemic lupus erythematosus that is chronically stable at this point.,2.  carpal tunnel involving the left wrist with sensory change, but no evidence of motor change.,3.  upper respiratory infection with cough, cold, and congestion.,recommendations:,1.  the patient will have a trial of a resting wrist splint at night for the next 4 to 6 weeks.  if there is no improvement, the patient will return for corticosteroid injection of her carpal tunnel.,2.  azithromycin 5-day dose pack.,3.  robitussin cough and cold flu to be taken twice a day.,4.  atarax 25 mg at bedtime for sleep.,5.  the patient will return to the rheumatology clinic for a routine followup evaluation in 4 months.",34
"general: , a well-developed infant in no acute respiratory distress.,vital signs:  ,initial temperature was xx, pulse xx, respirations xx.  weight xx grams, length xx cm, head circumference xx cm.,heent:  ,head is normocephalic with anterior fontanelle open, soft, and non-bulging.  eyes:  red reflex elicited bilaterally.  tms occluded with vernix and not well visualized.  nose and throat are patent without palatal defect.,neck: , supple without clavicular fracture.,lungs:,  clear to auscultation.,heart:,  regular rate without murmur, click, or gallop present.  pulses are 2/4 for brachial and femoral.,abdomen:,  soft with bowel sounds present.  no masses or organomegaly.,genitalia: , normal.,extremities: , without evidence of hip defects.,neurologic:  ,the infant has good moro, grasp, and suck reflexes.,skin: , warm and dry without evidence of rash.",28
"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.",35
"s - ,this patient has reoccurring ingrown infected toenails.  he presents today for continued care.,o - ,on examination, the left great toenail is ingrown on the medial and lateral toenail border.  the right great toenail is ingrown on the lateral nail border only.  there is mild redness and granulation tissue growing on the borders of the toes.  one on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  these lesions measure 0.5 cm in diameter each.  i really do not understand why this young man continues to develop ingrown nails and infections.,a - ,1.  onychocryptosis.,",30
"history of present illness: ,i have seen abc today for her preoperative visit for weight management.  i have explained to her the need for optifast for weight loss prior to these procedures to make it safer because of the large size of her liver.  she understands this.,impression/plan:, we are going to put her on two weeks of optifast at around 900 calories.  i have also explained the risks and potential complications of laparoscopic cholecystectomy to her in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, injury to the small intestine, stomach, liver, leak from the cystic duct, common bile duct, and possible need for ercp and further surgery.  this surgery is going to be planned for october 6.  this is for cholelithiasis prior to her lap-banding procedure.,i have also reviewed with her the risks and potential complications of laparoscopic gastric banding including bleeding, infection, deep venous thrombosis, pulmonary embolism, slippage of the band, erosion of the band, injury to the esophagus, stomach, small intestine, large intestine, spleen, liver, injury to the band, port, or tubing necessitating replacement of the band, port, or tubing among other potential complications and she understands.  we are going to proceed for laparoscopic gastric banding.  i have reviewed her entire chart in detail.  i have also gone over with her the fairfield county bariatrics consent form for banding and all the risks.  she has also signed the st. vincent's hospital consent form for lap-banding.  she has taken the preoperative quiz for banding.  she has signed the preop and postop instructions, and understands them and we reviewed them.  she has taken the quiz and done fairly well.  we have reviewed with her any potential other issues and i have answered her questions.  she is planned for surgical intervention.,",2
"circumcision,after informed consent was obtained the baby was placed on the circumcision tray.  he was prepped in a sterile fashion times 3 with betadine and then draped in a sterile fashion.  then 0.2 ml of 1% lidocaine was injected at 10 and 2 o'clock.  a ring block was also done using another 0.3 ml of lidocaine.  glucose water is also used for anesthesia.  after several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus.  the blunt probe was then introduced again with care taken to avoid the meatus.  after initial adhesions were taken down the straight clamp was introduced to break down further adhesions.  care was taken to avoid the frenulum.  the clamps where then repositioned at 12 and 6 o'clock.  the mogen clamp was then applied with a dorsal tilt.  after the clamp was applied for 1 minute the foreskin was trimmed.  after an additional minute the clamp was removed and the final adhesions were taken down.  patient tolerated the procedure well with minimal bleeding noted.  patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,routine care discussed with the family.  need to clean the area with just water initially and later with soap and water or diaper wipes once healed.",38
"procedures undertaken,1.  left coronary system cineangiography.,2.  right coronary system cineangiography.,3.  cineangiography of svg to om.,4.  cineangiography of lima to lad.,5.  left ventriculogram.,6.  aortogram.,7.  percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,narrative:,  after all risks and benefits were explained to the patient, informed consent was obtained.  the patient was brought to the cardiac catheterization suite.  the right groin was prepped in the usual sterile fashion.  right common femoral artery was cannulated using a modified seldinger technique and a long 6-french ao sheath was introduced secondary to tortuous aorta.  next, judkins left catheter was used to engage the left coronary system.  cineangiography was recorded in multiple views.  next, judkins right catheter was used to engage the right coronary system.  cineangiography was recorded in multiple views.  next, the judkins right catheter was used to engage the svg to om.  cineangiography was recorded.  next, the judkins right was advanced into the left subclavian and exchanged over a long exchange length j-wire for a 4-french left internal mammary artery which was used to engage the lima graft to lad and cineangiography was recorded in multiple views.  next, an angled pigtail catheter was advanced into the left ventricular cavity.  lv pressures were measured.  lv gram was done and a pullback gradient across the aortic valve was done and recorded.  next, an aortogram was done and recorded.  at this point, i decided to proceed with percutaneous intervention of the left circumflex.  therefore, ava 3.5 guide was used to engage the left coronary artery.  angiomax bolus and drip was started.  universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  we next attempted a cutting balloon.  again, we are unable to cross the lesion, therefore a buddy wire technique was used with a pt choice support wire.  again, we were unable to cross the lesion with the stent.  we then try to cross with a noncompliant balloon, which we were unsuccessful.  we also try to cutting balloon again, we were unsuccessful.  despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  final images showed no evidence of dissection, perforation, or further complication.  the right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  the patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,diagnostic findings,1.  the lv.  lvedp was 4.  lves is approximately 50%-55% with inferobasal hypokinesis.  no significant mr. no gradient across the aortic valve.,2.  aortogram.  the ascending aorta shows no significant dilatation or evidence of dissection.  the valve shows no significant aortic insufficiencies.  the abdominal aorta and distal aorta shows significant tortuosities.,3.  the left main.  the left main coronary artery is a large caliber vessel, bifurcating the lad and left circumflex with some mild distal disease of about 10%-20%.,4.  left circumflex.  the left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  the upper pole of the om shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  the mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  lad.  the lad is a totally 100% occluded vessel.  the lima to lad is patent with only a small-to-moderate caliber lad.  there is a large diagonal branch coming off the proximal portion of the lad and that proximal lad showed some diffuse disease upwards of 60%-70%.  the diagonal shows proximal 80% stenosis.,6.  the right coronary artery:  the right coronary artery is 100% occluded.  there are retrograde collaterals from left to right to the distal pda and plv branches.  the svg to om is 100% occluded at its take off.  the svg to pda is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  lima to lad is widely patent.,assessment and plan: , attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  final images showed some improvement, however, continued residual stenosis.  at this point, the patient will be transferred back to telemetry floor and monitored.  we can attempt future intervention or continue aggressive medical management.  the patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, i did not attempt intervention to that diagonal branch.  possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.",3
"preoperative diagnosis: , stenosing tendinosis, right thumb (trigger finger).,postoperative diagnosis: , stenosing tendinosis, right thumb (trigger finger).,procedure performed:,  release of a1 pulley, right thumb.,anesthesia:,  iv regional with sedation.,complications: , none.,estimated blood loss: , minimal.,tourniquet time: , approximately 20 minutes at 250 mmhg.,intraoperative findings: , there was noted to be thickening of the a1 pulley.  there was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,history:  ,this is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb.  she was actually able to spontaneously trigger the thumb.  she was diagnosed with stenosing tendinosis and wishes to proceed with release of a1 pulley.  all risks and benefits of the surgery was discussed with her at length.  she was in agreement with the above treatment plan.,procedure:  ,on 08/21/03, she was taken to operating room at abcd general hospital and placed supine on the operating table.  a regional anesthetic was applied by the anesthesia department.  tourniquet was placed on her proximal arm.  the upper extremity was sterilely prepped and draped in the usual fashion.,an incision was made over the proximal crease of the thumb.  subcuticular tissues were carefully dissected.  hemostasis was controlled with electrocautery.  the nerves were identified and retracted throughout the entire procedure.  the fibers of the a1 pulley were identified.  they were sharply dissected to release the tendon.  the tendon was then pulled up into the wound and inspected.  there was no evidence of gross tear noted.  fibrous nodule was noted within the tendon itself.  there was no evidence of continuous locking.  once release of the pulley had been performed, the wound was copiously irrigated.  it was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures.  sterile dressing was applied to the upper extremity.  tourniquet was deflated.  it was noted that the thumb was warm and pink with good capillary refill.  the patient was transferred to recovery in apparent stable and satisfactory condition.  prognosis is fair.",26
"procedure: , medial branch rhizotomy, lumbosacral.,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.,sedation: , the patient was given conscious sedation and monitored throughout the procedure.  oxygenation was given.  the patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,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 with a pillow under the abdomen to reduce the natural lumbar lordosis.  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 spine and the planned needle approach.  the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine.  with fluoroscopy, a teflon coated needle, ***, was gently guided into the region of the medial branch nerves from the dorsal ramus of ***.  specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  needle localization was confirmed with ap and lateral radiographs.,the following technique was used to confirm placement at the medial branch nerves.  sensory stimulation was applied to each level at 50 hz; paresthesias were noted at,*** volts.  motor stimulation was applied at 2 hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  at each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the medial branch nerve and surrounding tissue.  after completion of each nerve block a lesion was created at that level with a temperature of 85 degrees celsius for 90 seconds.  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.",26
"indications:,",3
"chief complaint:,  neck pain, thoracalgia, low back pain, bilateral lower extremity pain.,history of present illness:,  ms. xyz is a fairly healthy 69-year-old richman, roseburg resident who carries a history of chronic migraine, osteoarthritis, hypothyroidism, hyperlipidemia, and mitral valve prolapse.  she has previously been under the care of dr. ninan matthew in the 1990s and takes maxalt on a weekly basis and nadolol, omeprazole and amitriptyline for treatment of her migraines, which occur about once a week.  she is under the care of dr. bonaparte for hyperlipidemia and hypothyroidism.  she has a long history of back and neck pain with multiple injuries in the 1960s, 1970s, 1980s and 1990s.  in 2000, she developed ""sciatica"" mostly in her right lower extremity.,she is seen today with no outside imaging, except with mri of her cervical spine and lumbar spine dated february of 2004.  her cervical mri reveals an 8 mm central spinal canal at c6-7, multilevel foraminal stenosis, though her report is not complete as we do not have all the pages.  her lumbar mri reveals lumbar spinal stenosis at l4-5 with multilevel facet arthropathy and spondylitic changes.,the patient has essentially three major pain complaints.,her first pain complaint is one of a long history of axial neck pain without particular radicular symptoms.  she complains of popping, clicking, grinding and occasional stiffness in her neck, as well as occasional periscapular pain and upper trapezius myofascial pain and spasms with occasional cervicalgic headaches.  she has been told by dr. megahed in the past that she is not considered a surgical candidate.  she has done physical therapy twice as recently as three years ago for treatment of her symptoms.  she complains of occasional pain and stiffness in both hands, but no particular numbness or tingling.,her next painful complaint is one of midthoracic pain and thoracalgia features with some right-sided rib pain in a non-dermatomal distribution.  her rib pain was not preceded by any type of vesicular rash and is reproducible, though is not made worse with coughing.  there is no associated shortness of breath.  she denies inciting trauma and also complains of pain along the costochondral and sternochondral junctions anteriorly.  she denies associated positive or negative sensory findings, chest pain or palpitations, dyspnea, hemoptysis, cough, or sputum production.  her weight has been stable without any type of constitutional symptoms.,her next painful complaint is one of axial low back pain with early morning pain and stiffness, which improves somewhat later in the day.  she complains of occasional subjective weakness to the right lower extremity.  her pain is worse with sitting, standing and is essentially worse in the supine position.  five years ago, she developed symptoms radiating in an l5-s1 distribution and within the last couple of years, began to develop numbness in the same distribution.  she has noted some subjective atrophy as well of the right calf.  she denies associated bowel or bladder dysfunction, saddle area hypoesthesia, or falls.  she has treated her back symptoms with physical therapy as well.,she is intolerant to any type of antiinflammatory medications as well and has a number of allergies to multiple medications.  she participates in home physical therapy, stretching, hand weights, and stationary bicycling on a daily basis.  her pain is described as constant, shooting, aching and sharp in nature and is rated as a 4-5/10 for her average and current levels of pain, 6/10 for her worst pain, and 3/10 for her least pain.  exacerbating factors include recumbency, walking, sleeping, pushing, pulling, bending, stooping, and carrying.  alleviating factors including sitting, applying heat and ice.,past medical history:,  as per above and includes hyperlipidemia, hypothyroidism, history of migraines, acid reflux symptoms, mitral valve prolapse for which she takes antibiotic prophylaxis.,past surgical history:,  cholecystectomy, eye surgery, d&c.,medications:,  vytorin, synthroid, maxalt, nadolol, omeprazole, amitriptyline and 81 mg aspirin.,allergies:,  multiple.  all over-the-counter medications.  toradol, robaxin, midrin, darvocet, naprosyn, benadryl, soma, and erythromycin.,family history:,  family history is remarkable for a remote history of cancer. family history of heart disease and osteoarthritis.,social history:,  the patient is retired.  she is married with three grown children.  has a high school level education.  does not smoke, drink, or utilize any illicit substances.,oswestry pain inventory:,  significant impact on every aspect of her quality of life.  she would like to become more functional.,review of systems:,  a thirteen-point review of systems was surveyed including constitutional, heent, cardiac, pulmonary, gi, gu, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological.  cardiac, swelling in the extremities, hyperlipidemia, history of palpitation, varicose veins.  pulmonary review of systems negative.  gi review of systems is positive for irritable bowel and acid reflux symptoms.  genitourinary, occasional stress urinary incontinence and history of remote hematuria.  she is postmenopausal and on hormone replacement.  endocrine is positive for a low libido and thyroid disorder.  integument:  dry skin, itching and occasional rashes.  immunologic is essentially negative.  musculoskeletal:  as per hpi.  heent:  jaw pain, popping, clicking, occasional hoarseness, dysphagia, dry mouth, and prior history of toothache.  neurological:  as per history of present illness.  constitutional:  as history of present illness.,physical examination:,  weight 180 pounds, temp 97.6, pulse 56, bp 136/72.  the patient walks with a normal gait pattern.  there is no antalgia, spasticity, or ataxia.  she can alternately leg stand without difficulty, as well as tandem walk, stand on the heels and toes without difficulty.  she can flex her lumbar spine and touch the floor with her fingertips.  lumbar extension and ipsilateral bending provoke her axial back pain.  there is tenderness over the psis on the right and no particular pelvic asymmetry.,head is normocephalic and atraumatic.  cranial nerves ii through xii are grossly intact.  cervical range of motion is slightly limited in extension, but is otherwise intact to flexion and lateral rotation.  the neck is supple.  the trachea is midline.  the thyroid is not particularly enlarged.  lungs are clear to auscultation.  heart has regular rate and rhythm with normal s1, s2.  no murmurs, rubs, or gallops.  the abdomen is nontender, nondistended, without palpable organomegaly, guarding, rebound, or pulsatile masses.  skin is warm and dry to the touch with no discernible cyanosis, clubbing or edema.  i can radial, dorsalis pedis and posterior tibial pulses.  the nailbeds on her feet have trophic changes.  brisk capillary refill is evident over both upper extremities.,musculoskeletal examination reveals medial joint line tenderness of both knees with some varus laxity of the right lower extremity.  she has chronic osteoarthritic changes evident over both hands.  there is mild restriction of range of motion of the right shoulder, but no active impingement signs.,inspection of the axial skeleton reveals a cervicothoracic head-forward posture with slight internal rotation of the upper shoulders.  palpation of the axial skeleton reveals mild midline tenderness at the lower lumbar levels one fingerbreadth lateral to the midline.  there is no midline spinous process tenderness over the cervicothoracic regions.  palpation of the articular pillars is met with mild provocation of pain.  palpation of the right posterior, posterolateral and lateral borders of the lower ribs is met with mild provocable tenderness.  there is also tenderness at the sternochondral and costochondral junctions of the right, as well as the left bilaterally.  the xiphoid process is not particularly tender.  there is no dermatomal sensory abnormality in the thoracic spine appreciated.  mild facetal features are evident over the sacral spine with extension and lateral bending at the level of the sacral ala.,neurological examination of the upper and lower extremities reveals 3/5 reflexes of the biceps, triceps, brachioradialis, and patellar bilaterally.  i cannot elicit s1 reflexes.  there are no long tract signs.  negative hoffman's, negative spurling's, no clonus, and negative babinski.  motor examination of the upper, as well as lower extremities appears to be intact throughout.  i may be able to detect a slight hand of atrophy of the right calf muscles, but this is truly unclear and no measurement was made.,summary of diagnostic imaging:,  as per above.,impression:,1.  osteoarthritis.,2.  cervical spinal stenosis.,3.  lumbar spinal stenosis.,4.  lumbar radiculopathy, mostly likely at the right l5-s1 levels.,5.  history of mild spondylolisthesis of the lumbosacral spine at l4-l5 and right sacroiliac joint dysfunction.,6.  chronic pain syndrome with myofascial pain and spasms of the trapezius and greater complexes.,plan:  ,the natural history and course of the disease was discussed in detail with mr. xyz.  greater than 80 minutes were spent facet-to-face at this visit.  i have offered to re-image her cervical and lumbar spine and have included a thoracic mr imaging and rib series, as well as cervicolumbar flexion and extension views to evaluate for mobile segment and/or thoracic fractures.  i do not suspect any sort of intrathoracic comorbidity such as a neoplasm or mass, though this was discussed.  pending the results of her preliminary studies, this should be ruled out.  i will see her in followup in about two weeks with the results of her scans.",5
"indication:  ,",37
"p.o. box 12345,city, state ,re: examinee : abc,claim number : 12345-67890,date of injury : april 20, 2003,date of examination : august 26, 2003,examining physicians : y z, dc,prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. it is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. it has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,chief complaints: , improved focal lower back pain.,history: , abc is a 26-year-old man who immigrated to this country approximately six years ago. he speaks ""un poquito"" english and an interpreter is provided. he has worked for the last four years at floragon forest products, where he normally functions as a ""stacker."" he indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. he was doing this on april 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. he demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. he did not hit his upper back or neck or shoulders, and only sat down on the step as described. he had ""a little"" pain in his back at that time, but was able to get up and continue working. he completed his shift that day and returned to work the following day. he had the next two days off. he says that his symptoms persisted and increased, and on april 25, 2003, he went to the first choice physicians chiropractic and rehab clinic, where he came under the care of dr. abcd, dc. the file contains an entrance form completed by mr. abc which indicates at the bottom under ""previous occurrence of the same pain"" a notation of ""yes, but it was not really the same, it was just a little and tolerable."" there is an additional note on the side which states ""no pain prior to this injury or on that day, occasional (but low back)."" saw this notation, he says today that he did not state this and that the form was done by ""edna"" at dr. abcd's office.,mr. abc was initially treated three times a week and states that this has now been reduced to twice per week. he does not know how long the chiropractic treatment is to continue. initially, he has been seen by dr. xyz on three occasions, the last being on august 15, 2003. dr. xyz has basically referred him back to dr. abcd for continued chiropractic management.,mr. abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. he does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. he denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. he does not participate physically in any sports or hobbies that would be a factor.,present complaints: , mr. abc indicates at this time that he is overall better in that initially he had difficulty ""moving."" he grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. he now has ""good and bad days"" which depends on his activity level noting that he is better over the weekend. he localizes his pain to the midline lumbosacral region. he states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. he occasionally will notice some tightness behind both knees, but again no radicular type of distribution. he denies any focal muscular weakness or sphincter disturbance. his quality of the pain at this time is a ""tightness"" which bothers him, again, primarily with bending at the waist and lifting. he is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,past history: , mr. abc denies any prior similar complaints or treatments. he denies any previous specific lower back injury. he has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. he has seasonal allergies only with no known drug hypersensitivities. he has not been hospitalized overnight and has had no surgeries in his life. he currently takes otc advil and tylenol for lower back pain, but no prescriptive medication. he does not smoke, drink, or use street drugs of any type. review of systems and family history are generally noncontributory.,socio-economic history: , mr. abc, as indicated, was born and reared in mexico and immigrated into this country six years ago.,education: he has our equivalent of a high school education in mexico with no additional formal education in united states.,military history: he has no military experience in his life.,work history: he currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. he is not receiving any workers compensation or other benefits at this time.,physical examination: , abc presents as a cooperative and straightforward 26-year-old hispanic male. he has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. he is right hand dominant. he is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. he did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. lumbar lordosis is normal. he ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,active lumbar ranges of motion with double inclinometer are:,flexion 70 degrees.,extension 20 degrees.,side bending symmetric at 28 degrees.,he complains of lower back pain at the extremes of flexion only. motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. babinski's are neutral, and there is no clonus.,manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. cross leg with rotation hip joint motion is full on either side without reported hip or back pain. hip flexion is symmetric at 130 degrees, again without complaint. leg lengths appeared visually symmetric. mid calf girth is 11-1/2 inches bilaterally. five inches above the knees measured 13 inches right and left. the seated slr is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,in the prone position, he has good gluteal strength on either side with yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. no sacroiliac fixation is identified. hibbs test is negative on either side.,on palpation, he reports midline tenderness at l5-s1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. he indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. no definitive muscular spasm is noted in the lumbar paraspinal musculature.,mr. abc tolerated the examination process without apparent or expressed ill effect. ,imaging studies:,  ap and lateral lumbar/pelvic views dated may 15, 2003 are reviewed. the films are negative for recent fracture or pathology. there appears to be a transitional lumbosacral area with a spatulated transverse process of l1 and slight narrowing of the lumbosacral disc space. no additional abnormalities are identified. the hip and sacroiliac articulations appear well preserved. disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. soft tissue appeared normal without paraspinal mass or abnormality.,diagnosis: , lumbosacral contusion/strain relative to the april 20, 2003 industrial accident - objectively resolved.,summary: , discussion and recommendations in response to questions posed in your august 15, 2003 letter:,1. what is your diagnosis of the worker's condition as a result of the injury? please provide objective medical findings that support your diagnosis. please indicate if the objective findings are reproducible, measurable, or observable, and how.,the diagnosis of the workers condition secondary to the described april 20, 2003 fall is by history a lumbosacral contusion/strain. this impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. in your opinion, is the work injury a contributing cause of the diagnosis? if so, is the work injury the material contributing cause of the diagnosis? please provide an explanation for your opinion.,it would appear that the work injury was the major contributing cause of the diagnosis.,3. are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).",18
"subjective:,  the patient is here for a follow-up.  the patient has a history of lupus, currently on plaquenil 200-mg b.i.d.  eye report was noted and appreciated.  the patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  she denied having any trauma.  she states that the pain is bothering her.  she denies having any fevers, chills, or any joint effusion or swelling at this point.  she noted also that there is some increase in her hair loss in the recent times.,objective:,  the patient is alert and oriented.  general physical exam is unremarkable.  musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  hand examination is unremarkable today.  the rest of the musculoskeletal exam is unremarkable.,assessment:,  epicondylitis, both elbows, possibly secondary to lupus flare-up.,plan:,  we will inject both elbows with 40-mg of kenalog mixed with 1 cc of lidocaine.  the posterior approach was chosen under sterile conditions.  the patient tolerated both procedures well.  i will obtain cbc and urinalysis today.  if the patient's pain does not improve, i will consider adding methotrexate to her therapy.,sample doctor m.d.",26
"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.",10
"chief complaint:, left foot pain.,history:, xyz is a basketball player for university of houston who sustained an injury the day prior. they were traveling. he came down on another player's foot sustaining what he describes as an inversion injury. swelling and pain onset immediately. he was taped but was able to continue playing he was examined by john houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. he has been in a walking boot. he has been taped firmly. pain with weightbearing activities. he is limping a bit. no significant foot injuries in the past. most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,physical exam:, he does have some swelling from the hindfoot out toward the midfoot. his arch is maintained. his motion at the ankle and subtalar joints is preserved. forefoot motion is intact. he has pain with adduction and abduction across the hindfoot. most of this discomfort is laterally. his motor strength is grossly intact. his sensation is intact, and his pulses are palpable and strong. his ankle is not tender. he has minimal to no tenderness over the atfl. he has no medial tenderness along the deltoid or the medial malleolus. his anterior drawer is solid. his external rotation stress is not painful at the ankle. his tarsometatarsal joints, specifically 1, 2 and 3, are nontender. his maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. some tenderness over the dorsolateral side of the talonavicular joint as well. the medial talonavicular joint is not tender.,radiographs:, those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. i don't see a definite fracture. the tarsometarsal joints are anatomically aligned. radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. review of an mr scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. also some changes along the dorsal talonavicular joint. i don't see any significant marrow edema or definitive fracture line. ,impression:,  left chopart joint sprain.,plan:,  i have spoken to xyz about this. continue with ice and boot for weightbearing activities. we will start him on a functional rehab program and progress him back to activities when his symptoms allow. he is clear on the prolonged duration of recovery for these hindfoot type injuries.",26
"procedure performed,1.  placement of a subclavian single-lumen tunneled hickman central venous catheter.,2.  surgeon-interpreted fluoroscopy.,operation 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 anesthesia was administered.  next, a #18-gauge needle was used to locate the subclavian vein.  after aspiration of venous blood, a j wire was inserted through the needle using seldinger technique.  the needle was withdrawn.  the distal tip location of the j wire was confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  next, a separate stab incision was made approximately 3 fingerbreadths below the wire exit site.  a subcutaneous tunnel was created, and the distal tip of the hickman catheter was pulled through the tunnel to the level of the cuff.  the catheter was cut to the appropriate length.  a dilator and sheath were passed over the j wire.  the dilator and j wire were removed, and the distal tip of the hickman catheter was threaded through the sheath, which was simultaneously withdrawn.  the catheter was flushed and aspirated without difficulty.  the distal tip was confirmed to be in good location with surgeon-interpreted fluoroscopy.  a 2-0 nylon was used to secure the cuff down to the catheter at the skin level.  the skin stab site was closed with a 4-0 monocryl.  the instrument and sponge count was correct at the end of the case.  the patient tolerated the procedure well and was transferred to the postanesthesia recovery area in good condition.",3
"reason for neurological consultation: , cervical spondylosis and kyphotic deformity.  the patient was seen in conjunction with medical resident dr. x. i personally obtained the history, performed examination, and generated the impression and plan.,history of present illness: ,the patient is a 45-year-old african-american female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  this has subsequently resolved.  she started vigorous workouts in november 2005.  in march of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  by her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  she had an mri of lumbosacral spine, which was within normal limits.  she then developed a tingling sensation in the right middle toe.  symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  she then started getting sensory sensations in the left hand and arm.  she states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  symptoms have been mildly progressive.  she is unaware of any trigger other than the vigorous workouts as mentioned above.  she has no associated bowel or bladder symptoms.  no particular position relieves her symptoms.,workup has included two mris of the c-spine, which were personally reviewed and are discussed below.  she saw you for consultation and the possibility of surgical decompression was raised.  at this time, she is somewhat reluctant to go through any surgical procedure.,past medical history:,1.  ocular migraines.,2.  myomectomy.,3.  infertility.,4.  hyperglycemia.,5.  asthma.,6.  hypercholesterolemia.,medications: , lipitor, pulmicort, allegra, xopenex, patanol, duac topical gel, loprox cream, and rhinocort.,allergies: , penicillin and aspirin.,family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  of note, she does not drink or smoke.  she is married with two adopted children.  she is a paralegal specialist.  she used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,review of systems: , she does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,physical examination: , on examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  pain scale is 0.  a full general and neurological examination was personally performed and is documented on the chart.  of note, she has a normal general examination.  neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  she has mild postural tremor in both arms.  she has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  she has hyperreflexia in her lower extremities, worse on the left.  babinski's are downgoing.,pertinent data:  ,mri of the brain from 05/02/06 and mri of the c-spine from 05/02/06 and 07/25/06 were personally reviewed.  mri of the brain is broadly within normal limits.  mri of the c-spine reveals large central disc herniation at c6-c7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  there is also a fairly large disc at c3-c4 with cord deformity and partial effacement of the subarachnoid space.  i do not appreciate any cord edema at this level.,impression and plan:  ,the patient is a 45-year-old female with cervical spondylosis with a large c6-c7 herniated disc with mild cord compression and signal change at that level.  she has a small disc at c3-c4 with less severe and only subtle cord compression.  history and examination are consistent with signs of a myelopathy.,results were discussed with the patient and her mother.  i am concerned about progressive symptoms.  although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  if she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  i strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  i agree with the previous physicians who have told her not to exercise as i am sure that her vigorous workouts and weight training since november 2005 have contributed to this problem.  i have recommended that she wear a hard collar while driving.  the results of my consultation were discussed with you telephonically.",21
"preoperative diagnoses,1.  herniated nucleus pulposus, c5-c6.,2.  herniated nucleus pulposus, c6-c7.,postoperative diagnoses,1.  herniated nucleus pulposus, c5-c6.,2.  herniated nucleus pulposus, c6-c7.,procedure performed,1.  anterior cervical decompression, c5-c6.,2.  anterior cervical decompression, c6-c7.,3.  anterior spine instrumentation.,4.  anterior cervical spine fusion, c5-c6.,5.  anterior cervical spine fusion, c6-c7.,6.  application of machined allograft at c5-c6.,7.  application of machined allograft at c6-c7.,8.  allograft, structural at c5-c6.,9.  allograft, structural at c6-c7.,anesthesia: , general.,preoperative note:  ,this patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  preoperative mri scan showed evidence of herniated nucleus pulposus at c5-c6 and c6-c7 on the left.  the patient has failed epidural steroid injections.  risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,operative report: , the patient was taken to the or and placed in the supine position.  after general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  a horizontal incision was made on the left side of the neck at the level of the c6 vertebral body.  it was taken down through the subcutaneous tissues exposing the platysmus muscle.  the platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  an #18 gauge needle was placed in the c5-c6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  the disk was very degenerated and brown in color.  there was an acute disk herniation through posterior longitudinal ligament.  the posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  approximately, 5 mm of the nerve root on both the right and left side was visualized.  a ball-ended probe could be passed up the foramen.  bleeding was controlled with bipolar electrocautery and surgiflo.  the end plates of c5 and c6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  there was good bony apposition both proximally and distally.  next, attention was placed at the c6-c7 level.  again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at c6-c7 was performed.  the disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  the posterior longitudinal ligament was removed.  a bilateral foraminotomy was performed.  approximately, 5 mm of the c7 nerve root was visualized on both sides.  a micro nerve hook was able to be passed up the foramen easily.  bleeding was controlled with bipolar electrocautery and surgiflo.  the end plates at c6-c7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  there was good bony apposition, both proximally and distally.  next, a 44-mm blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  the wound was then copiously irrigated with normal saline and bacitracin.  there was no active bleeding upon closure of the wound.  a small drain was placed deep.  the platysmal muscle was closed with 3-0 vicryl.  the skin was closed with #4-0 monocryl.  mastisol and steri-strips were applied.  the patient was monitored throughout the procedure with free-running emgs and sseps and there were no untoward events.  the patient was awoken and taken to the recovery room in satisfactory condition.",37
"preoperative diagnosis: , osteomyelitis, left hallux.,postoperative diagnosis: , osteomyelitis, left hallux.,procedures performed: , resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,anesthesia: , tiva/local.,history:,  this 77-year-old male presents to abcd preoperative holding area after keeping himself npo since mid night for surgery on his infected left hallux.  the patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  he has failed outpatient antibiotic therapy and conservative methods.  at this time, he desires to attempt surgical correction.  the patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  he was counseled preoperatively about the strong probability of the hallux being a ""floppy tail"" after the surgery and accepts the fact.  the risks versus benefits of the procedure were discussed with the patient in detail by dr. x and the consent is available on the chart for review.,procedure in detail:  ,the patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  the wound was on the planar medial, distal and dorsal medial.  the wound's bases were fibrous.  they did not break the bone at this point.  they were each approximately 0.5 cm in diameter.  after iv was established by the department of anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  next, a total of 3 cc of a 1:1 mixture of 0.5% marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  next, the foot was prepped and draped in the usual aseptic fashion.  it was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  next, the incision was deepened through the subcutaneous tissue.  a heavy amount of bleeding was encountered.  therefore, a penrose drain was applied at the tourniquet, which failed.  next, an esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  the long extensor tendon was thickened and overall exhibited signs of hypertrophy.  the transverse incision through the long extensor tendon was made with a #15 blade.  immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  next, the extensor tendon was peeled dorsally and distally off the bone.  immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  this bone was removed with a sharp dissection.  next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  this was passed off as the infected bone specimen for microbiology and pathology.  next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  the pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  this bone was found to be hard and healthy appearing.  the wound after irrigation was free of all debris and infected tissue.  therefore anaerobic and aerobic cultures were taken and sent to microbiology.  next, osteoset beads, tobramycin-impregnated, were placed.  six beads were placed in the wound.  next, the extensor tendon was re-approximated with #3-0 vicryl.  the subcutaneous layer was closed with #4-0 vicryl in a simple interrupted technique.  next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,the esmarch bandage was released and immediate hyperemic flush was noted at the digits.  a standard postoperative dressing was applied consisting of 4 x 4s, betadine-soaked #0-1 silk, kerlix, kling, and a loosely applied ace wrap.  the patient tolerated the above anesthesia and procedure without complications.  he was transported via a cart to the postanesthesia care unit.  his vitals signs were stable and vascular status was intact.  he was given a medium postop shoe that was well-formed and fitting.  he is to elevate his foot, but not apply ice.  he is to follow up with dr. x.  he was given emergency contact numbers.  he is to continue the vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  the patient was discharged in stable condition.",30
"subjective: , the patient was seen and examined.  he feels much better today, improved weakness and decreased muscular pain.  no other complaints.,physical examination:,general:  not in acute distress, awake, alert and oriented x3.,vital signs:  blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, o2 saturation 99% on 3 l.,heent:  nc/t, perrla, eomi.,neck:  supple.,heart: regular rate and rhythm.,respiratory:  clear bilateral.,abdomen:  soft and nontender.,extremities:  no edema.  pulses present bilateral.,laboratory data: , total ck coming down 70,142 from 25,573, total ck is 200, troponin is 2.3 from 1.9 yesterday.,bnp, blood sugar 93, bun of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and co2 of 22.,liver function test, ast 704, alt 298, alkaline phosphatase 67, total bilirubin 0.3.  cbc, wbc count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  blood cultures are still pending.,ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  doppler of lower extremities negative for dvt., ,assessment and plan:,1.  rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  continue iv fluids.  we will monitor.,2.  acute on chronic renal failure.  we will follow up with nephrology recommendation.,3.  anemia, drop in hemoglobin most likely hemodilutional.  repeat cbc in a.m.,4.  leukocytosis, improving.,5.  elevated liver enzyme, most likely secondary to rhabdomyolysis.  the patient denies any abdominal pain and ultrasound is unremarkable.,6.  hypertension.  blood pressure controlled.,7.  elevated cardiac enzyme, follow up with cardiology recommendation.,8.  obesity.,9.  deep venous thrombosis prophylaxis.  continue lovenox 40 mg subcu daily.",34
"procedures:,1.  release of ventral chordee.,2.  circumcision.,3.  repair of partial duplication of urethral meatus.,indications: , the patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding.  he is here electively for surgical correction.,description of procedure: , the patient was brought back into operating room 35.  after successful induction of general endotracheal anesthetic, giving the patient, preoperative antibiotics and after completing a preoperative time out, the patient was prepped and draped in the usual sterile fashion.,a holding stitch was placed in the glans penis.  at this point, we probed both urethral meatus.  using the crede maneuver, we could see urine clearly coming out of the lower, the more ventral meatus.  at this point, we cannulated this with a 6-french hypospadias catheter.  we attempted to cannulate the dorsal opening, however, we were unsuccessful.  we then attempted to place lacrimal probes and were also unsuccessful indicating this was incomplete duplication.  at this point, we identified the band connecting both the urethral meatus and incised it with tenotomy scissors.  we sutured both meatus together such that there was one meatus at the normal position at the tip of the glans.,at this point, we made a circumcising incision around the penis and degloved the penis in its entirety relieving all chordee.  once all the chordee had been adequately released, we turned our attention to the circumcision.  excessive dorsal foreskin was removed from the skin and glans.  mucosal cuts were reapproximated with interrupted 5-0 chromic suture.  dermabond was placed over this and bacitracin was placed on this once dry.  this ended the procedure.  ,drains:,  none.,estimated blood loss: , minimal.,urine output:  ,unrecorded.,complications: , none apparent.,disposition:  ,the patient will now go under the care of dr. xyz, plastic surgery, for excision of scalp hemangioma.",38
"preoperative diagnosis: , abdominal aortic aneurysm.,postoperative diagnosis: , abdominal aortic aneurysm.,operation performed:,  endovascular abdominal aortic aneurysm repair.,findings: , the patient was brought to the or with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  a gore exclusive device was used 3 pieces were used to effect the repair.  we had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  the right hypogastric artery had been previously coiled off.  left common femoral artery was used for the _____ side.  we had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type i leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  it was felt that this would seal after reversal of the anticoagulation given sufficient time.,procedure: , with the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  the patient was then heparinized.,the 7-french sheaths were then placed retrograde bilaterally.,a stiff amplatz wires were then placed up the right femoral artery and a stiff amplatz were placed left side a calibrated catheter was placed up the right side.  the calibrated aortogram was the done.  we marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  we then preceded placement of the main trunk, by replacing the 7 french sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  as noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,following completion of the above all arteries were ballooned appropriately.  a completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  the area was ballooned aggressively.  it was felt that this would dissolve as discussed above.,following completion of the above all wire sheaths etc., were removed from both groin areas.  both femoral arteries were repaired by primary suture technique.  flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,both surgical sites were then irrigated thoroughly.  meticulous hemostasis was achieved.  both wounds were then closed in a routine layered fashion.,sterile antibiotic dressings were applied.  sponge and needle counts were reported as correct.  the patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.",37
"procedures: , total knee replacement.,procedure description:,  the patient was bought to the operating room and placed in the supine position.  after induction of anesthesia, a tourniquet was placed on the upper thigh.  sterile prepping and draping proceeded.  the tourniquet was inflated to 300 mmhg.  a midline incision was made, centered over the patella.  dissection was sharply carried down through the subcutaneous tissues.  a median parapatellar arthrotomy was performed.  the lateral patellar retinacular ligaments were released and the patella was retracted laterally.  proximal medial tibia was denuded, with mild release of medial soft tissues.  the acl and pcl were released.  the medial and lateral menisci and suprapatellar fat pad were removed.  these releases allowed for anterior subluxation of tibia.  an extramedullary tibial cutting jig was pinned to the proximal tibia in the appropriate alignment and flush cut was made along tibial plateau, perpendicular to the axis of the tibia.  its alignment was checked with the rod and found to be adequate.  the tibia was then allowed to relocate under the femur.,an intramedullary hole was drilled into the femur and a femoral rod attached to the anterior cutting block was inserted, and the block was pinned in appropriate position, judging correct rotation using a variety of techniques.  an anterior rough cut was made.  the distal cutting jig was placed atop this cut surface and pinned to the distal femur, and the rod was removed.  the distal cut was performed.,a spacer block was placed, and adequate balance in extension was adjusted and confirmed, as was knee alignment.  femoral sizing was performed with the sizer, and the appropriate size femoral 4-in-1 chamfer-cutting block was pinned in place and the cuts were made.  the notch-cutting block was pinned to the cut surface, slightly laterally, and the notch cut was then made.  the trial femoral component was impacted onto the distal femur and found to have an excellent fit.  a trial tibial plate and polyethylene were inserted, and stability was judged and found to be adequate in all planes.  appropriate rotation of the tibial component was identified and marked.  the trials were removed and the tibia was brought forward again.  the tibial plate size was checked and the plate was pinned to plateau.  a keel guide was placed and the keel was then made.  the femoral intramedullary hole was plugged with bone from the tibia.  the trial tibial component and poly placed; and, after placement of the femoral component, range of motion and stability were checked and found to be adequate in various ranges of flexion and extension.,the patella was held in a slightly everted position with knee in extension.  patellar width was checked with calipers.  a free-hand cut of the patellar articular surface was performed and checked to ensure symmetry with the calipers.  sizing was then performed and 3 lug holes were drilled with the jig in place, taking care to medialize and superiorize the component as much as possible, given bony anatomy.  any excess lateral patellar bone was recessed.  the trial patellar component was placed and found to have adequate tracking.  the trials were removed; and as the cement was mixed, all cut surfaces were thoroughly washed and dried.  the cement was applied to the components and the cut surfaces with digital pressurization, and then the components were impacted.  the excess cement was removed from the gutters and anterior and posterior parts of the knee.  the knee was brought into full extension with the trial polyethylene and further axially pressurized as cement hardened.  once the cement had hardened, the tourniquet was deflated.  the knee was dislocated again, and any excess cement was removed with an osteotome.  thorough irrigation and hemostasis were performed.  the real polyethylene component was placed and pinned.  further vigorous power irrigation was performed, and adequate hemostasis was obtained and confirmed.  the arthrotomy was closed using 0 ethibond and vicryl sutures.  the subcutaneous tissues were closed after further irrigation with 2-0 vicryl and monocryl sutures.  the skin was sealed with staples.  xeroform and a sterile dressing were applied followed by a cold-pack and ace wrap.  the patient was transferred to the recovery room in stable condition, having tolerated the procedure well.",26
"title of operation: , youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,preoperative diagnosis: , hallux limitus deformity of the right foot.,postoperative diagnosis: , hallux limitus deformity of the right foot.,anesthesia:,  monitored anesthesia care with 15 ml of 1:1 mixture of 0.5% marcaine and 1% lidocaine plain.,estimated blood loss:,  less than 10 ml.,hemostasis:,  right ankle tourniquet set at 250 mmhg for 35 minutes.,materials used: , 3-0 vicryl, 4-0 vicryl, and two partially threaded cannulated screws from 3.0 osteomed system for internal fixation.,injectables:  ,ancef 1 g iv 30 minutes preoperatively.,description of the procedure: , the patient was brought to the operating room and placed on the operating table in the supine position.  after adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  the right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmhg.  the right ankle tourniquet was then inflated.  the right foot was prepped, scrubbed, and draped in normal sterile technique.  attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  the incision was deepened through the subcutaneous tissues.  all the bleeders were identified, cut, clamped, and cauterized.  the incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  all the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  the decision was thus made to perform a youngswick-type osteotomy on the head of the first right metatarsal.  the osteotomy consistent of two dorsal cuts and a plantar cut in a v-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  the two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  the wedge of bone that was formed between the two dorsal cuts was resected and passed off to pathology for further examination.  the head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the osteomed system.  the wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  the wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the osteomed system.  the 2 screws were inserted using ao technique.  upon insertion of the screws, the two wires were removed.  fixation of the osteotomy on the table was found to be excellent.  the area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  the cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  the capsule and periosteal tissues were then reapproximated with 3-0 vicryl suture material, 4-0 vicryl was used to approximate the subcutaneous tissues.  steri-strips were used to approximate and reinforce the skin edges.  at this time, the right ankle tourniquet was deflated.  immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  the patient's surgical site was then covered with xeroform, copious amounts of fluff and kling, stockinette, and ace bandage.  the patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  the patient was given instructions and education on how to continue caring for her right foot surgery at home.  the patient was also given pain medication instructions on how to control her postoperative pain.  the patient was eventually discharged from hospital according to nursing protocol and was advised to follow up with dr. x's office in one week's time for her first postoperative appointment.",37
"subjective: , the patient is not in acute distress.,physical examination:,vital signs:  blood pressure of 121/63, pulse is 75, and o2 saturation is 94% on room air.,head and neck:  face is symmetrical.  cranial nerves are intact.,chest:  there is prolonged expiration.,cardiovascular:  first and second heart sounds are heard.  no murmur was appreciated.,abdomen:  soft and nontender.  bowel sounds are positive.,extremities:  he has 2+ pedal swelling.,neurologic:  the patient is asleep, but easily arousable.,laboratory data:,  ptt is 49.  inr is pending.  bun is improved to 20.6, creatinine is 0.7, sodium is 123, and potassium is 3.8.  ast is down to 45 and alt to 99.,diagnostic studies: , nuclear stress test showed moderate size, mostly fixed defect involving the inferior wall with a small area of peri-infarct ischemia.  ejection fraction is 25%.,assessment and plan:,1.  congestive heart failure due to rapid atrial fibrillation and systolic dysfunction.  continue current treatment as per cardiology.  we will consider adding ace inhibitors as renal function improves.,2.  acute pulmonary edema, resolved.,3.  rapid atrial fibrillation, rate controlled.  the patient is on beta-blockers and digoxin.  continue coumadin.  monitor inr.,4.  coronary artery disease with ischemic cardiomyopathy.  continue beta-blockers.,5.  urinary tract infection.  continue rocephin.,6.  bilateral perfusion secondary to congestive heart failure.  we will monitor.,7.  chronic obstructive pulmonary disease, stable.,8.  abnormal liver function due to congestive heart failure with liver congestion, improving.,9.  rule out hypercholesterolemia.  we will check lipid profile.,10.  tobacco smoking disorder.  the patient has been counseled.,11.  hyponatremia, stable.  this is due to fluid overload.  continue diuresis as per nephrology.,12.  deep venous thrombosis prophylaxis.  the patient is on heparin drip.",3
"preoperative diagnosis:,  right renal mass.,postop diagnosis: , right renal mass.,procedure performed:,  laparoscopic right radical nephrectomy.,estimated blood loss:,  100 ml.,x-rays: , none.,specimens: , right radical nephrectomy specimen.,complications: , none.,anesthesia:  ,general endotracheal.,drains:,  16-french foley catheter per urethra.,brief history: , the patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  this is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  i discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  all questions were answered, and she wished to proceed with surgery as planned.,procedure in detail:,  after acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  after institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  all pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-french foley catheter per urethra to gravity drainage.  the abdomen was insufflated in the right outer quadrant.  note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  the abdomen was insufflated into the right lateral abdomen with veress needle to 50 mm of pressure without incident.  we then placed a 10/12 visiport trocar approximately 7 cm lateral to the umbilicus.  once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  there were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,we began nephrectomy procedure by reflecting the right colon, by incising the white line of toldt.  this exposed the retroperitoneum on the right side.  the duodenum was identified and reflected medially in a kocher maneuver using sharp dissection only.  we then identified the ureter and gonadal vein in the retroperitoneum.  the gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  sequential packets of tissue were taken using primarily the ligasure atlas device.  once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  we proceeded then and skeletonized the structures into four individual packets.  we then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  the adrenal was spared during this procedure.  there was no contiguous connection between the renal mass and a right adrenal gland.  this plane of dissection was taken down primarily using the ligasure device.  we then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo gi stapler and then to renal veins again with endo gi stapler sequential flaring.  once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  the lateral attachments of the kidney were taken down using the ligasure atlas device, and then the ureter was doubly clipped and transected.  the kidney was then freed within the retroperitoneum.  a 50-mm endocatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  we extended the lower most trocar site approximately 6 cm to facilitate extraction.  the kidney was removed and passed off the table as a specimen for pathology.  this was bivalved by pathology, and we reviewed the specimen.",37
"subjective:,  his brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  the patient started improving his diet when he received the letter explaining his lipids are elevated.  he is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  he has started packing his lunch three to four times per week instead of eating out so much.  he is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  he is in training for a triathlon.  he says he is already losing weight due to his efforts.,objective:,  height:  6 foot 2 inches.  weight:  204 pounds on 03/07/05.  ideal body weight:  190 pounds, plus or minus ten percent.  he is 107 percent standard of midpoint ideal body weight.  bmi:  26.189.  a 48-year-old male.  lab on 03/15/05:  cholesterol:  251.  ldl:  166.  vldl:  17.  hdl:  68.  triglycerides:  87.  i explained to the patient the dietary guidelines to help improve his lipids.  i recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  i went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  i encouraged him to continue as he is doing.,assessment:,  basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  his 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  he needs to continue as he is doing.  he verbalized understanding and seemed receptive.,plan:,  the patient plans to recheck his lipids through dr. xyz  i gave him my phone number and he is to call me if he has any further questions regarding his diet.",5
"reason for consultation: , questionable need for antibiotic therapy for possible lower extremity cellulitis.,history of present illness: , the patient is a 51-year-old caucasian female with past medical history of morbid obesity and chronic lower extremity lymphedema.  she follows up at the wound care center at hospital.  her lower extremity edema is being managed there.  she has had multiple episodes of cellulitis of the lower extremities for which she has received treatment with oral bactrim and ciprofloxacin in the past according to her.  as her lymphedema was not improving on therapy at that facility, she was referred for admission to long-term acute care facility for lymphedema management.  she at present has a stage ii ulcer on the lower part of the medial aspect of left leg without any drainage and has slight erythema of bilateral lower calf and shin areas.  her measurements for lymphedema wraps have been taken and in my opinion, it is going to be started in a day or two.,i have been consulted to rule out the possibility of lower extremity cellulitis that may require antibiotic therapy.,past medical history:,  positive for morbid obesity, chronic lymphedema of the lower extremities, at least for the last three years, spastic colon, knee arthritis, recurrent cellulitis of the lower extremities.  she has had a hysterectomy and a cholecystectomy in the remote past.,social history: , the patient lives by herself and has three pet cats.  she is an ex-smoker, quit smoking about five years ago.  she occasionally drinks a glass of wine.  she denies any other recreational drugs use.  she recently retired from state of pennsylvania as a psychiatric aide after 32 years of service.,family history: , positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia.  one of her uncles was diagnosed with leukemia.,allergies: , adhesive tape allergies.,review of systems:,  at present, the patient is admitted with a nonresolving bilateral lower extremity lymphedema, which is a little bit more marked on the right lower extremity compared to the left.  she denies any nausea, vomiting or diarrhea.  she denies any pain, tenderness, increased warmth or drainage from the lower extremities.  denies chest pain, cough or phlegm production.  all other systems reviewed were negative.,physical examination:,general:  a 51-year-old morbidly obese caucasian female who is not in any acute hemodynamic distress at present.,vital signs:  her maximum recorded temperature since admission today is 96.8, pulse is 65 per minute, respiratory rate is 18 to 20 per minute, blood pressure is 150/54, i do not see a recorded weight at present.,heent:  pupils are equal, round, and reactive to light.  extraocular movements intact.  head is normocephalic and external ear exam is normal.,neck:  supple.  there is no palpable lymphadenopathy.,cardiovascular system:  regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.  heart sounds are little distant secondary to thick chest wall.,lungs:  clear to auscultation and percussion bilaterally.,abdomen:  morbidly obese, soft, nontender, nondistended, there is no percussible organomegaly, there is no evidence of lymphedema on the abdominal pannus.  there is no evidence of cutaneous candidiasis in the inguinal folds.  there is no palpable lymphadenopathy in the inguinal and femoral areas.,extremities:  bilateral lower extremities with evidence of extensive lymphedema, there is slight pinkish discoloration of the lower part of calf and shin areas, most likely secondary to stasis dermatosis.  there is no increased warmth or tenderness, there is no skin breakdown except a stage ii chronic ulcer on the lower medial aspect of the right calf area.  it has minimal serosanguineous drainage and there is no surrounding erythema.  therefore, in my opinion, there is no current evidence of cellulitis or wound infection.  there is no cyanosis or clubbing.  there is no peripheral stigmata of endocarditis.,central nervous system:  the patient is alert and oriented x3, cranial nerves ii through xii are intact, and there is no focal deficit appreciated.,laboratory data: , white cell count is 7.4, hemoglobin 12.9, hematocrit 39, platelet count of 313,000, differential is normal with 51% neutrophils, 37% lymphocytes, 9% monocytes and 3% eosinophils.  the basic electrolyte panel is within normal limits and the renal function is normal with bun of 17 and creatinine of 0.5.  liver function tests are also within normal limits.,the nasal screen for mrsa is negative.  urine culture is negative so far from admission.  urinalysis was negative for pyuria, leucocyte esterase, and nitrites.,impression and plan:,  a 51-year-old caucasian female with multiple medical problems mentioned above including history of morbid obesity and chronic lower extremity lymphedema.  admitted for inpatient management of bilateral lower extremity lymphedema.  i have been consulted to rule out possibility of active cellulitis and wound infection.,at present, i do not find evidence of active cellulitis that needs antibiotic therapy.  in my opinion, lymphedema wraps could be initiated.  we will continue to monitor her legs with lymphedema wraps changes 2 to 3 times a week.  if she develops any cellulitis, then appropriate antibiotic therapy will be initiated. ,her stage ii ulcer on the right leg does not look infected.  i would recommend continuation of wound care along with lymphedema wraps.,other medical problems will continue to be followed and treated by dr. x's group during this hospitalization.  dr. y from plastic surgery and lymphedema management clinic is following.,i appreciate the opportunity of participating in this patient's care.  if you have any questions, please feel free to call me at any time.  i will continue to follow the patient along with you 2-3 times per week during this hospitalization at the long-term acute care facility.",15
"reason for followup:,  care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with cpr and advanced cardiac life support.,history of present illness: , this is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  previously while treating this patient i had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated ca-125 and a complex mass located in the ovary.  as the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  however, last night the patient had apparently catastrophic event around 2:40 in the morning.  rapid response was called and the patient was intubated, started on pressure support, and given cpr.  this morning i was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  the patient was seen and examined, she was intubated and sedated.  limbs were cool.  cardiovascular exam revealed tachycardia.  lungs had coarse breath sounds.  abdomen was soft.  extremities were cool to the touch.  pupils were 6 to 2 mm, doll's eyes were not intact.  they were not responsive to light.  based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  all pressure support was discontinued.  the patient was started on intravenous morphine and respiratory was requested to remove the et tube.  monitors were turned off and the patient was made as comfortable as possible.  family is at the bedside at this time.  the patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.",15
"preoperative dx:, dermatochalasis, mechanical ptosis, brow ptosis.,postoperative dx:, same,procedure:,: upper lid blepharoplasty and direct brow lift,anesthesia:, local with sedation,indications for surgery: , in the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  these field losses resolved with upper eyelid taping which simulates the expected surgical correction.  photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  the risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,description of procedure:, on the day of surgery, the surgical site and procedure were verified by the physician with the patient.  an informed consent was signed and witnessed.  emla cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  two drops of topical proparacaine eye drops were placed on the ocular surface.  the skin was cleaned with alcohol prep pads.  the patient received 3 to 4 ml of 2% lidocaine with epinephrine and 0.5% marcaine mixture to each upper lid.  5 to 6 ml of local were also given to the brow region along the entire length.  pressure was applied over each site for 5 minutes.  the patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,the desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  the contour of the outline was created to provide a greater temporal lift.  care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  the incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  the dimensions of the redundant tissue measured * horizontally and * vertically.  the redundant tissue was removed sharply with westcott scissors.  hemostasis was maintained with hand held cautery and/or electrocautery.  the closure was carried out in multiple layers.  the deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  the intermediate layer was closed with 5-0 vicryl similarly.  the skin was closed with 6-0 nylon in a running lock fashion.  iced saline gauze pads were placed over the incision sites.  this completed the brow repair portion of the case.,using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  an angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  these lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  the desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  this tissue was outlined with a surgical marking pen.  care was taken to avoid excessive skin removal near the brow region.  a surgical ruler was used to ensure symmetry.  the skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  this layer was removed with westcott scissors.,hemostasis was achieved with high-temp hand held pen cautery.  the remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  the high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  care was taken to not disturb the levator aponeurosis.  a symmetric amount of fat was removed from each side.  iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  saline gauze and cold packs were placed over the upper lids.  the patient was taken from the surgical suite in good condition.,discharge:,  in the recovery area the results of surgery were discussed with the patient and their family.  specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  instructions on antibiotic ointment use were reviewed.  the incision sites were checked prior to release.  the patient was released to home with a driver after vital signs were deemed stable.",25
"preoperative diagnosis: , low back pain.,postoperative diagnosis: , low back pain.,procedure performed:,1.  lumbar discogram l2-3.,2.  lumbar discogram l3-4.,3.  lumbar discogram l4-5.,4.  lumbar discogram l5-s1.,anesthesia:  ,iv sedation.,procedure in detail:  ,the patient was brought to the radiology suite and placed prone onto a radiolucent table.  the c-arm was brought into the operative field and ap, left right oblique and lateral fluoroscopic images of the l1-2 through l5-s1 levels were obtained.  we then proceeded to prepare the low back with a betadine solution and draped sterile.  using an oblique approach to the spine, the l5-s1 level was addressed using an oblique projection angled c-arm in order to allow for perpendicular penetration of the disc space.  a metallic marker was then placed laterally and a needle entrance point was determined.  a skin wheal was raised with 1% xylocaine and an #18-gauge needle was advanced up to the level of the disc space using ap, oblique and lateral fluoroscopic projections.  a second needle, #22-gauge 6-inch needle was then introduced into the disc space and with ap and lateral fluoroscopic projections, was placed into the center of the nucleus.  we then proceeded to perform a similar placement of needles at the l4-5, l3-4 and l2-3 levels.,a solution of isovue 300 with 1 gm of ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.",32
"history of present illness: , the patient is a 41-year-old african-american male previously well known to me.  he has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  there is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  he has a previous history of transient ischemic attack with no residual neurologic deficits.,the patient has undergone surgery by dr. x for attempted nephrolithotomy.  the patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  the patient is presently seen at the request of dr. x for management of anticoagulation and his above heart disease.,past medical and surgical history:,1.  type i diabetes mellitus.,2.  hyperlipidemia.,3.  hypertension.,4.  morbid obesity.,5.  sleep apnea syndrome.,6.  status post thyroidectomy for thyroid carcinoma.,review of systems:,general:  unremarkable.,cardiopulmonary:  no chest pain, shortness of breath, palpitations, or dizziness.,gastrointestinal:  unremarkable.,genitourinary:  see above.,musculoskeletal:  unremarkable.,neurologic:  unremarkable.,family history: , there are no family members with coronary artery disease.  his mother has congestive heart failure.,social history:  ,the patient is married.  he lives with his wife.  he is employed as a barber.  he does not use alcohol, tobacco, or illicit drugs.,medications prior to admission:,1.  clonidine 0.3 mg b.i.d.,2.  atenolol 50 mg daily.,3.  simvastatin 80 mg daily.,4.  furosemide 40 mg daily.,5.  metformin 1000 mg b.i.d.,6.  hydralazine 25 mg t.i.d.,7.  diovan 320 mg daily.,8.  lisinopril 40 mg daily.,9.  amlodipine 10 mg daily.,10.  lantus insulin 50 units q.p.m.,11.  kcl 20 meq daily.,12.  novolog sliding scale insulin coverage.,13.  warfarin 7.5 mg daily.,14.  levothyroxine 0.2 mg daily.,15.  folic acid 1 mg daily.,allergies: , none.,physical examination:,general:  a well-appearing, obese black male.,vital signs:  bp 140/80, hr 88, respirations 16, and afebrile.,heent:  grossly normal.,neck:  normal.  thyroid, normal.  carotid, normal upstroke, no bruits.,chest:  midline sternotomy scar.,lungs:  clear.,heart:  pmi fifth intercostal space mid clavicular line.  normal s1 and prosthetic s2.  no murmur, rub, gallop, or click.,abdomen:  soft and nontender.  no palpable mass or hepatosplenomegaly.",5
"title of procedure: , percutaneous liver biopsy.,analgesia: , 2% lidocaine.,allergies: , the patient denied any allergy to iodine, lidocaine or codeine.,procedure in detail:  ,the procedure was described in detail to the patient at a previous clinic visit and by the medical staff today.  the patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death.  the risks and benefits of the procedure were understood, and the patient signed the consent form freely.,with the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.  the area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver.  next, a small incision was made with a bard-parker #11 scalpel.  a 16-gauge modified klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration.  liver cores measuring *** cm were obtained and will be sent to pathology for routine histologic study.,post-procedure course and disposition: , the patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication.  normal activities can be resumed tomorrow.  the patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop.  an appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,complications:,  none.,recommendations: , prior to discharge, hepatitis a and b vaccines will be recommended.  risks and benefits for vaccination have been addressed and the patient will consider this option.",14
"chief complaint:  ,the patient does not have any chief complaint.,history of present illness:,  this is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  the next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  the neighbor suspects that this may have been due to the patient taking too many of her tylenol pm, which the patient has been known to do.  the patient was a little somnolent early this morning and was found only to be oriented x1 with ems upon their arrival to the patient's house.  the patient states that she just simply felt funny and does not give any more specific details than this.  the patient denies any pain at any time.  she did not have any shortness of breath.  no nausea or vomiting.  no generalized weakness.  the patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  the patient's primary care physician, dr. x reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  the patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her copd and chf.  the patient was discharged home after evaluation in the emergency room.  the patient does use home o2.,review of systems: , constitutional:  the patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  the patient denies having any other symptoms today.  the patient denies any fever or chills.  has not had any recent weight change.  heent:  the patient denies any headache.  no neck pain.  no rhinorrhea.  no sinus congestion.  no sore throat.  no any vision or hearing change.  no eye or ear pain.  cardiovascular:  the patient denies any chest pain.  respirations:  no shortness of breath.  no cough.  no wheeze.  the patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  gastrointestinal:  no abdominal pain.  no nausea or vomiting.  no change in the bowel movements.  there has not been any diarrhea or constipation.  no melena or hematochezia.  genitourinary:  no dysuria, hematuria, urgency, or frequency.  musculoskeletal:  no back pain.  no muscle or joint aches.  no pain or abnormalities to any portion of the body.  skin:  no rashes or lesions.  neurologic:  the patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  the patient denies any dizziness at this time.  no syncope or no near-syncope.  the patient denies any focal weakness or numbness.  no speech change.  no difficulty with ambulation.  the patient has not had any vision or hearing change.  psychiatric:  the patient denies any depression.  endocrine:  no heat or cold intolerance.,past medical history:,  copd, chf, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,past surgical history:,  placement of pacemaker and hysterectomy.,current medications: , the patient takes tylenol pm for insomnia, lasix, coumadin, norvasc, lanoxin, diovan, atenolol, and folic acid.,allergies:,  no known drug allergies.,social history: , the patient used to smoke, but quit approximately 30 years ago.  the patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,physical examination: , vital signs:  temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  constitutional:  the patient is well nourished and well developed.  the patient appears to be healthy.  the patient is calm, 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 sclerae and cornea bilaterally.  nose is normal without rhinorrhea or audible congestion.  mouth and oropharynx are normal without any sign of infection.  mucous membranes are moist.  neck:  supple and nontender.  full range of motion.  there is no jvd.  no cervical lymphadenopathy.  no carotid artery or vertebral artery bruits.  cardiovascular:  heart is regular rate and rhythm without murmur, rub or gallop.  peripheral pulses are +2.  the patient does have +1 bilateral lower extremity edema.  respirations:  the patient has coarse breath sounds bilaterally, but no dyspnea.  good air movement.  no wheeze.  no crackles.  the patient speaks in full sentences without any difficulty.  the patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  gastrointestinal:  abdomen is soft, nontender, and nondistended.  no rebound or guarding.  no hepatosplenomegaly.  normal bowel sounds.  no bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  musculoskeletal:  no abnormalities noted to the back, arms or legs.  skin:  no rashes or lesions.  neurological:  cranial nerves ii through xii are intact.  motor is 5/5 and equal to bilateral arms and legs.  sensory is intact to light touch.  the patient has normal speech and normal ambulation.  psychiatric:  the patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  the patient has normal mood and affect.  hematologic and lymphatic:  there is no evidence of lymphadenopathy.,emergency department testing: , ekg is a rate of 72 with evidence of a pacemaker that has good capture.  there is no evidence of acute cardiac disease on the ekg and there is no apparent change in the ekg from 03/17/08.  cbc has no specific abnormalities of issue.  chemistry has a bun of 46 and creatinine of 2.25, glucose is 135, and an estimated gfr is 20.  the rest of the values are normal and unremarkable.  lfts are all within normal limits.  cardiac enzymes are all within normal limits.  digoxin level is therapeutic at 1.6.  chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  cat scan of the head did not identify any acute abnormalities.  i spoke with the patient's primary care physician, dr. x who stated that he would be able to follow up with the patient within the next day.  i spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her tylenol pm as she often has done in the past.  the neighbor is xyz and he says that he checks on her three times a day every day.  abc is the patient's son and although he lives out of town he calls and checks on her every day as well.  he states that he spoke to her yesterday.  she sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  she sounded her usual self to him.  mr. abc also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  he states that he will be able to check on her tomorrow as well.  although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a nursing home in the past, but dr. y states that she has managed to be discharged after two previous nursing home placements.  the patient does have home health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  the patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,diagnoses,1.  early dementia.,2.",12
"subjective:,  this 46-year-old white male with down’s syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis.  he has finished six weeks of lamisil without any problems.  he is due to have an alt check today.  at his appointment in april, i also found that he was hypothyroid with elevated tsh.  he was started on levothroid 0.1 mg and has been taking that daily.  we will recheck a tsh today as well.  his mother notes that although he does not like to take the medications, he is taking it with encouragement.  his only other medications are some eyedrops for his cornea.,objective:,  weight was 149 pounds, which is up 2 pounds.  blood pressure was 120/80.  pulse is 80 and regular.,neck:  supple without adenopathy.  no thyromegaly or nodules were palpable.,cardiac:  regular rate and rhythm without murmurs.,skin:  examination of the toenails showed really no change yet.  they are still quite thickened and yellowed.,assessment:,1.  down’s syndrome.,2.  onychomycosis.,3.  hypothyroidism.,plan:,1.  recheck alt and tsh today and call results.,2.  lamisil 250 mg #30 one p.o. daily with one refill.  they will complete the next eight weeks of therapy as long as the alt is normal.  i again reviewed the symptoms of liver dysfunction.,3.  continue levothroid 0.1 mg daily unless dosage need to be adjusted based on the tsh.",34
"the patient made some progress during therapy.  she accomplished two and a half out of her five short-term therapy goals.  we did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  the patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  the patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  she also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  the patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  her last session occurred on 01/09/09.  she has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.",10
"subjective:,  this 23-year-old white female presents with complaint of allergies.  she used to have allergies when she lived in seattle but she thinks they are worse here.  in the past, she has tried claritin, and zyrtec.  both worked for short time but then seemed to lose effectiveness.  she has used allegra also.  she used that last summer and she began using it again two weeks ago.  it does not appear to be working very well.  she has used over-the-counter sprays but no prescription nasal sprays.  she does have asthma but doest not require daily medication for this and does not think it is flaring up.,medications: , her only medication currently is ortho tri-cyclen and the allegra.,allergies: , she has no known medicine allergies.,objective:,vitals:  weight was 130 pounds and blood pressure 124/78.,heent:  her throat was mildly erythematous without exudate.  nasal mucosa was erythematous and swollen.  only clear drainage was seen.  tms were clear.,neck:  supple without adenopathy.,lungs:  clear.,assessment:,  allergic rhinitis.,plan:,1.  she will try zyrtec instead of allegra again.  another option will be to use loratadine.  she does not think she has prescription coverage so that might be cheaper.,2.  samples of nasonex two sprays in each nostril given for three weeks.  a prescription was written as well.",34
"preoperative diagnoses:,1.  intrauterine pregnancy at 30 and 4/7th weeks.,2.  previous cesarean section x2.,3.  multiparity.,4.  request for permanent sterilization.,postoperative diagnosis:,1.  intrauterine pregnancy at 30 and 4/7th weeks.,2.  previous cesarean section x2.,3.  multiparity.,4.  request for permanent sterilization.,5.  breach presentation in the delivery of a liveborn female neonate.,procedures performed:,1.  repeat low transverse cesarean section.,2.  bilateral tubal ligation (btl).,tubes: , none.,drains: , foley to gravity.,estimated blood loss: , 600 cc.,fluids:,  200 cc of crystalloids.,urine output:,  300 cc of clear urine at the end of the procedure.,findings:,  operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  there were bowel adhesions noted through the anterior abdominal wall.  the uterus was noted to be within normal limits.  the tubes and ovaries bilaterally were noted to be within normal limits.  the baby was delivered from the right sacral anterior position without any difficulty.  apgars 8 and 9.  weight was 7.5 lb.,indications for this procedure:  ,the patient is a 23-year-old g3 p 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  she had her first c-section because of congenial hip problems.  in her second c-section, baby was breached, therefore, she is scheduled for a third c-section.  the patient also requests sterilization.  therefore, she requested a tubal ligation.,procedure: , after informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with astramorph anesthesia was obtained without any difficulty.  she was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  a pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  the fascia was excised in the midline extended laterally with the mayo scissors.  the superior aspect of the fascial incision was then tented up with ochsner clamps and the underlying rectus muscle dissected off sharply with the metzenbaum scissors.  there was noted dense adhesions at this point as well as a wire mesh was noted.  the anterior aspect of the fascial incision was then tented up with ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  the rectus muscle superiorly was opened with a hemostat.  the peritoneum was identified and entered bluntly digitally.  the peritoneal incision was then extended superiorly up to the level of the mesh.  then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  the bladder blade was inserted and vesicouterine peritoneum was identified and tented up with allis clamps and bladder flap was created sharply with the metzenbaum scissors digitally.  the bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the bandage scissors.  the amniotic fluid was noted to be clear.  at this point, upon examining the intrauterine contents, the baby was noted to be breached.  the right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  the cord was clamped and the baby was then handed off to awaiting pediatricians.  the placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  the uterus was exteriorized and cleared of all clots and debris.  then, the uterine incision was then closed with #0 vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  attention at this time was turned to the tubes bilaterally.,both tubes were isolated and followed all the way to the fimbriated end and tented up with the babcock clamp.  the hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the metzenbaum scissors.  the ends was then burned with the cautery and then using a #2-0 vicryl suture tied down.  both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  the uterus was then replaced back into the abdomen.  the gutters were cleared of all clots and debris.  the uterine incision was then once again inspected and noted to be hemostatic.  the bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  the peritoneum was then closed with #3-0 vicryl in a running fashion.  then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 vicryl in a simple stitch fashion.  the fascia was then closed with #0 vicryl in a running fashion.  the subcutaneous layer and scarpa's fascia were repaired with a #3-0 vicryl.  then, the skin edges were reapproximated using sterile clips.  the dressing was placed.  the uterus was then cleared of all clots and debris manually.  then, the patient tolerated the procedure well.  sponge, lap, and needle, counts were correct x2.  the patient was taken to recovery in sable condition.  she will be followed up throughout her hospital stay.",23
"reason for exam:  this 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under ct guidance at the request of dr. x.,procedure:  the procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient.  the patient understood.  all questions were answered, and informed consent was obtained.  with the patient in the prone position, noncontrasted ct localization images were obtained through the kidney.  conscious sedation was utilized with the patient being monitored.  the patient was administered divided dose of versed and fentanyl intravenously.,following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach.  two biopsy specimens were obtained and placed in 10% formalin solution.  ct documented needle placement.  following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly.  i placed several torpedo pledgets of gelfoam through the co-axial sheath into the site of bleeding.  the bleeding stopped.  the co-axial sheath was then removed.  bandage was applied.  hemostasis was obtained.  the patient was placed in the supine position.  postbiopsy ct images were then obtained.  the patient's hematoma appeared stable.  the patient was without complaints of pain or discomfort.  the patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable.  the patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with dr. fieldstone for the results and follow-up care.,findings:  initial noncontrasted ct localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney.  images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass.  images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass.  there are small droplets of air within the hematoma.  no hydronephrosis is identified.,conclusion:,1.  percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2.  development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with gelfoam pledgets.",37
"exam:,mri cervical spine,clinical:, a57-year-old male. received for outside consultation is an mri examination performed on 11/28/2005.,findings:,normal brainstem-cervical cord junction. normal cisterna magna with no tonsillar ectopia. normal clivus with a normal craniovertebral junction. normal anterior atlantoaxial articulation.,c2-3: normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. normal central canal and intervertebral neural foramina with no cord or radicular impingement.,c3-4: there is disc desiccation with minimal annular bulging. the residual ap diameter of the central canal measures approximately 10mm. csf remains present surrounding the cord.,c4-5: there is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. the residual ap diameter of the central canal measures approximately 8mm with effacement of the circumferential csf cleft producing a borderline central canal stenosis but no cord distortion or cord edema. there is minimal uncovertebral joint arthrosis.,c5-6: there is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (ap x transverse). the disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,c6-7: there is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. the residual ap diameter of the central canal measures 8 mm with effacement of the circumferential csf cleft. there is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left c7 nerve root.,c7-t1, t1-2: minimal disc desiccation with no disc displacement or endplate spondylosis.,impression:,multilevel degenerative disc disease as described above.,c4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,c5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,c6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left c7 nerve root with a borderline central canal stenosis.,normal cervical cord.",26
"preoperative diagnoses:,1.  cardiac tamponade.,2.  status post mitral valve repair.,postoperative diagnoses:,1.  cardiac tamponade.,2.  status post mitral valve repair.,procedure performed: , mediastinal exploration with repair of right atrium.,anesthesia: , general endotracheal.,indications: , the patient had undergone mitral valve repair about seven days ago.  he had epicardial pacing wires removed at the bedside.  shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  he was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  he was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,details of procedure:  ,the patient was taken emergently to the operating room and placed supine on the operating room table.  his chest was prepped and draped prior to induction under general anesthesia.  incision was made through the previous median sternotomy chest incision.  wires were removed in the usual manner and the sternum was retracted.  there were large amounts of dark blood filling the mediastinal chest cavity.  large amounts of clot were also removed from the pericardial well and chest.  systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  this was repaired with two horizontal mattress pledgeted #5-0 prolene sutures.  an additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  no other sites of bleeding were identified.  the mediastinum was then irrigated with copious amounts of antibiotic saline solution.  two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  the sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running vicryl sutures.  the skin was then closed with a running subcuticular stitch.  the patient was then taken to the intensive care unit in a critical but stable condition.",37
"history of present illness: , the patient is a 55-year-old gentleman who presents for further evaluation of right leg weakness.  he has difficulty recollecting the exact details and chronology of his problem.  to the best of his recollection, he thinks that about six months ago he developed weakness of his right leg.  he describes that he is reaching to get something from a cabinet and he noticed that he was unable to stand on his right toe.  since that time, he has had difficulty pushing off when he walks.  he has mild tingling and numbness in his toes, but this has been a chronic problem and nothing new since he has developed the weakness.  he has chronic mild back pain, but this has been persistent for many years and has not changed.  he has experienced cramps in both calves for the past year.  this dissipated about two months ago.  he does not think that his left leg is weak.  he does not have any bowel or bladder incontinence.  there is no radicular pain.  he does not think that the problem is progressive, meaning that the weakness that he perceives in his right leg is no different than when it was six months ago.,he first sought medical attention for this problem in october.  he then saw you a couple of months later.  he has undergone an emg and nerve conduction studies.  unfortunately, he cannot undergo an mri of his spine because he has an ear implant.  he has had a ct scan that shows degenerative changes, but nothing obviously abnormal.,in addition, the patient has hyperckemia.  he tells me that he has had an elevated ck prior to starting taking stat medications, although this is not entirely clear to me.  he thinks that he is not taking lipitor for about 15 months and thought that his ck was in the 500 or 600s prior to starting it.  once it was started, it increased to about 800 and then came down to about 500 when it was stopped.  he then had a recent bump again up to the 1000 and since lipitor has been stopped, his ck apparently has returned to about the 500 or 600s.  i do no have any laboratory data to support these statements by the patient, but he seems to be up to speed on this.  more recently, he has been started taking zetia.  he does not have any proximal weakness.  he denies any myalgias., ,past medical history:,  he has coronary artery disease and has received five stents.  he has hypertension and hypercholesterolemia.  he states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  he believes that his glucose shot up to over 300 with this testing.  he does not take any medications for this and his blood glucoses are generally normal when he checks it.  he has had plastic surgery on his face from an orbital injury.  he also had an ear graft when he developed an ear infection during his honeymoon., ,current medications:, he takes amlodipine, diovan, zetia, hydrochlorothiazide, lovaza (fish oil), niaspan, aspirin, and chantix.  , ,allergies:,  he has no known drug allergies., ,social history:,  he lives with his wife.  he works at shepherd pratt doing network engineering.  he smokes a pack of cigarettes a day and is working on quitting.  he drinks four alcoholic beverages per night.  prior to that, he drank significantly more.  he denies illicit drug use.  he was athletic growing up., ,family history:,  his mother died of complications from heart disease.  his father died of heart disease in his 40s.  he has two living brothers.  one of them he does not speak too much with and does not know about his medical history.  the other is apparently healthy.  he has one healthy child.  his maternal uncles apparently had polio.  when i asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg.  he is fairly certain that they had polio.  he is unaware of any other family members with neurological conditions.,review of systems: , he has occasional tinnitus.  he has difficulty sleeping.  otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  this is documented in the handwritten notes from today's visit.,physical examination:, ,vital signs:",21
"preoperative diagnosis: , chronic pelvic pain, probably secondary to endometriosis.,postoperative diagnosis:,  mild pelvic endometriosis.,procedure:,1.  attempted laparoscopy.,2.  open laparoscopy.,3.  fulguration of endometrial implant.,anesthesia: , general endotracheal.,blood loss: , minimal.,complications: , none.,indications:  ,the patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative gi workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of depo-lupron.,procedure: , after an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  she was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,in the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  the anterior lip of the cervix was grasped with a single-tooth tenaculum.  a hulka tenaculum was placed transcervically.  the other instruments were removed.  a foley catheter was placed transurethrally to drain the bladder intraoperatively.,in the low lithotomy position and in steep trendelenburg, attention was turned to the infraumbilical region.  here, a stab wound incision was made through which the 120 mm veress needle was placed and approximately 3 l of carbon dioxide used to create a pneumoperitoneum.  the needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  the trocar was removed and the scope placed confirming a preperitoneal insufflation.,the space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  the hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long allis clamp used to grasp the posterior fornix on which was placed traction.  the first short and subsequently 15 cm veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  it was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  the 15 cm veress needle was inserted several times, but again a pneumo was preperitoneal.,finally, an open laparoscopic approach was undertaken.  the skin incision was expanded with a knife blade.  blunt dissection was used to carry the dissection down to the fascia.  this was grasped with kocher clamps, entered sharply and opened transversely.  four 0 vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,at this juncture, the hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  in the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  the left tube and ovary were normal.  there were no adhesions.  there was no evidence of acute pelvic inflammatory disease.,the endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  pictures were taken for confirmation both before and after the burn.,the carbon chars were irrigated and aspirated.  the smoke plume was removed without difficulty.  approximately 50 ml of irrigant was left in the pelvis.  due to the difficulty in placing and maintaining the hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,the suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the hasson cannula removed.  the residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  finally, the skin incisions were approximated with 3-0 dexon subcuticularly.  they had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  the vaginal instruments were removed.  all counts were correct.  the patient tolerated the procedure well and was taken to the recovery room in stable condition.",37
"reason for referral: , ms. a is a 60-year-old african-american female with 12 years of education who was referred for neuropsychological evaluation by dr. x after she demonstrated mild cognitive deficits on a neuropsychological screening evaluation during a followup appointment with him for stroke in july.  a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,relevant background information:,  historical information was obtained from a review of available medical records and clinical interview with ms. a.  a summary of pertinent information is presented below.  please refer to the patient's medical chart for a more complete history.,history of presenting problem:,  ms. a presented to the abc hospital emergency department on 07/26/2009 reporting that after she had woken up that morning she noticed numbness and weakness in her left hand, slurred speech, and left facial droop.  neurological evaluation with dr. x confirmed left hemiparesis.  brain ct showed no evidence of intracranial hemorrhage or mass effect and that she received tpa and had moderate improvement in left-sided weakness.  these symptoms were thought to be due to a right middle cerebral artery stroke.  she was transferred to the icu for monitoring.  ultrasound of the carotids showed 20% to 30% stenosis of the right ica and 0% to 19% stenosis of the left ica.  on 07/29/2009, she was admitted for acute inpatient rehabilitation for the treatment of residual functional deficits of her acute ischemic right mca/cva.  at discharge on 08/06/2009, she was mainly on supervision for all adls and walking with a rolling walker, but tolerating increased ambulation with a cane.  she was discharged home with recommendations for outpatient physical therapy.  she returned to the sinai er on 08/2009/2009 due to reported left arm pain, numbness, and weakness, which lasted 10 to 15 minutes and she reported that it felt ""just like the stroke.""  brain ct on 08/2009/2009 was read as showing ""mild chronic microvascular ischemic change of deep white matter,"" but no acute or significant interval change compared to her previous scan.  neurological examination with dr. y was within normal limits, but she was admitted for a more extensive workup.  due to left arm pain an ultrasound was completed on her left upper extremity, but it did not show deep vein thrombosis.,followup ct on 08/10/2009 showed no significant interval change.  mri could not be completed due to the patient's weight.  she was discharged on 08/11/2009 in stable condition after it was determined that this event was not neurological in origin; however, note that ms. a referred to this as a second stroke.,ms. a presented for a followup outpatient neurological evaluation with dr. x on 09/22/2009, at which time a brief neuropsychological screening was also conducted.  she demonstrated significant impairments in confrontation naming, abstract verbal reasoning, and visual and verbal memory and thus a more comprehensive evaluation was suggested due to her intent to return to her full-time work duty.  during the current interview, ms. a reported that she noticed mild memory problems including some difficultly remembering conversations, events, and at times forgetting to take her medications.  she also reported mild difficulty finding words in conversation, solving novel problems and tasks (e.g. difficulty learning to use her camcorder), but overall denied significant cognitive deficits in attention, concentration, language or other areas of cognitive functioning.  when asked about her return to work, she said that she was still on light duty due to limited physical activity because of residual left leg weakness.  she reported that no one had indicated to her that she appeared less capable of performing her job duties, but said that she was also receiving fewer files to process and enter data into the computer at the social security agency that she works at.  note also that she had some difficulty explaining exactly what her job involved.  she also reported having problems falling asleep at work and that she is working full-time although on light duty.,other medical history:  ,as mentioned, ms. a continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly.  she was diagnosed with sleep apnea approximately two years ago and was recently counseled by dr. x on the need to use her cpap because she indicated she never used it at night.  she reported that since her appointment with dr. x, she has been using it ""every other night.""  when asked about daytime fatigue, ms. a initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen.  she reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point.  she receives approximately two to five hours of sleep per night.  other current untreated risk factors include obesity and hypercholesterolemia.  her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke).,current medications: , aspirin 81 mg daily, colace 100 mg b.i.d., lipitor 80 mg daily, and albuterol mdi p.r.n.,substance use:,  ms. a denied drinking alcohol or using illicit drugs.  she used to smoke a pack of cigarettes per day, but quit five to six years ago.,family medical history: , ms. a had difficulty providing information on familial medical history.  she reported that her mother died three to four years ago from lung cancer.  her father has gout and blood clots.  siblings have reportedly been treated for asthma and gi tumors.  she was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.,social history: , ms. a completed high school degree.  she reported that she primarily obtained b's and c's in school.  she received some tutoring for algebra in middle school, but denied ever having been held back a grade failing any classes or having any problems with attention or hyperactivity.,she currently works for the social security administration in data processing.  as mentioned, she has returned to full-time work, but continues to perform only light duties due to her physical condition.  she is now living on her own.  she has never driven.  she reported that she continues to perform adls independently such as cooking and cleaning.  she lost her husband in 2005 and has three adult daughters.  she previously reported some concerns that her children wanted her to move into assisted living, but she did not discuss that during this current evaluation.  she also reported number of other family members who had recently passed away.  she has returned to activities she enjoys such as quire, knitting, and cooking and plans to go on a cruise to the bahamas at the end of october.,psychiatric history: , ms. a did not report a history of psychological or psychiatric treatment.  she reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events.  she reported that this only ""comes and goes."",tasks administered:,clinical interview,adult history questionnaire,wechsler test of adult reading (wtar),mini mental status exam (mmse),cognistat neurobehavioral cognitive status examination,repeatable battery for the assessment of neuropsychological status (rbans; form xx),mattis dementia rating scale, 2nd edition (drs-2),neuropsychological assessment battery (nab),wechsler adult intelligence scale, third edition (wais-iii),wechsler adult intelligence scale, fourth edition (wais-iv),wechsler abbreviated scale of intelligence (wasi),test of variables of attention (tova),auditory consonant trigrams (act),paced auditory serial addition test (pasat),ruff 2 & 7 selective attention test,symbol digit modalities test (sdmt),multilingual aphasia examination, second edition (mae-ii),  token test,  sentence repetition,  visual naming,  controlled oral word association,  spelling test,  aural comprehension,  reading comprehension,boston naming test, second edition (bnt-2),animal naming test",31
"dear sample doctor:,thank you for referring mr. sample patient for cardiac evaluation.  this is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  he has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or pnd.  he is known to have a mother with coronary heart disease.  he has never been a smoker.  he has never had a syncopal episode, mi, or cva.  he had his gallbladder removed.  no bleeding tendencies.  no history of dvt or pulmonary embolism.  the patient is retired, rarely consumes alcohol and consumes coffee moderately.  he apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  he is allergic to codeine and aspirin (angioedema).,physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  his heart rate was 98 beats per minute and regular.  his blood pressure was 140/80 mmhg in the right arm in a sitting position and 150/80 mmhg in a standing position.  he is in no distress.  venous pressure is normal.  carotid pulsations are normal without bruits.  the lungs are clear.  cardiac exam was normal.  the abdomen was obese and organomegaly was not palpated.  there were no pulsatile masses or bruits.  the femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  there was no peripheral edema.  ,he had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  renal function was normal.  his lipid profile showed a slight increase in triglycerides with normal total cholesterol and hdl and an acceptable range of ldl.  his sodium was a little bit increased.  his a1c hemoglobin was increased.  he had a spirometry, which was reported as normal.  ,he had a resting electrocardiogram on december 20, 2002, which was also normal.  he had a treadmill cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  there were no symptoms or ischemia by ekg.  there was some suggestion of inferior wall ischemia with normal wall motion by cardiolite imaging.,in summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  i am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  he denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,in view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  i explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  he also should start aggressively losing weight.  i have requested additional testing today, which will include an apolipoprotein b, lpa lipoprotein, as well as homocystine, and cardio crp to further assess his risk of atherosclerosis.  ,in terms of medication, i have changed his verapamil for a long acting beta-blocker, he should continue on an ace inhibitor and his plavix.  the patient is allergic to aspirin.  i also will probably start him on a statin, if any of the studies that i have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which i believe he should.  this, however, i will leave entirely up to you to decide.  if indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,i do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,if you have any further questions, please do not hesitate to let me know.,thank you once again for this kind referral.,sincerely,,sample doctor, m.d.",19
"procedure:,1.  implantation, dual chamber icd.,2.  fluoroscopy.,3.  defibrillation threshold testing.,4.  venography.,procedure note: , after informed consent was obtained, the patient was taken to the operating room.  the patient was prepped and draped in a sterile fashion.  using modified seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  venogram was then performed.  under fluoroscopy via modified seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  a second guidewire was placed in a similar fashion.  approximately a 5 cm incision was made in the left upper anterior chest.  the skin and subcutaneous tissue was dissected out of the prepectoral fascia.  both guide wires were brought into the pocket area.  a sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  the dilator and guidewire were removed.  a fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  after pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with ethibond suture.  a guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  the dilator and guidewire were removed.  an active fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  using straight and j-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  after significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with ethibond suture.  the tract was flushed with saline solution.  a medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with ethibond suture.  deep and superficial layers were closed with 3-0 vicryl in a running fashion.  steri-strips were placed over the incision.  tegaderm was placed over the steri-strips.  pressure dressing was applied to the pocket area.",37
"date of admission:,  mm/dd/yyyy.,date of discharge: , mm/dd/yyyy.,referring physician: , ab cd, m.d.,attending physician at discharge:,  x y, m.d.,admitting diagnoses:,1.  ewing sarcoma.,2.  anemia.,3.  hypertension.,4.  hyperkalemia.,procedures during hospitalization:  ,cycle seven ifosfamide, mesna, and vp-16 chemotherapy.,history of present illness: , ms. xxx is a pleasant 37-year-old african-american female with the past medical history of ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  she presented initially with a left frontal orbital swelling to dr. xyz on mm/dd/yyyy.  a biopsy revealed small round cells and repeat biopsy on mm/dd/yyyy also showed round cells consistent with ewing sarcoma, genetic analysis indicated a t1122 translocation.  mri on mm/dd/yyyy showed a 4 cm soft tissue mass without bony destruction.  ct showed similar result.  the patient received her first cycle of chemotherapy on mm/dd/yyyy.  on mm/dd/yyyy, she was admitted to the ed with nausea and vomitting and was admitted to the hematology and oncology a service following her first course of chemotherapy.  she had her last course of chemotherapy on mm/dd/yyyy followed by radiation treatment to the ethmoid sinuses on mm/dd/yyyy.,hospital course: ,1.  ewing sarcoma, she presented for cycle seven of vp-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  she was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.",10
"operation performed:, phacoemulsification of cataract and posterior chamber lens implant, right eye., ,anesthesia:, retrobulbar nerve block, right eye, ,description of operation: ,the patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of betadine and a honan balloon.  once anesthesia was achieved, the right eye was prepped with betadine, rinsed with saline, and draped in a sterile fashion.  a lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe.  a fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field.  a surgical groove was applied with a 69 beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position.  a lamellar dissection was carried anteriorly to clear cornea using a crescent knife.  a stab incision was applied with a superblade at the 2 o'clock position at the limbus.  the chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion.  viscoat was injected into the chamber and an anterior capsulorrhexis performed.  hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber.  a deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision.  a second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants.  each quadrant was emulsified under burst power within the capsular bag.  the epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power.  i&a was used to aspirate cortex from the capsular bag.  a scratcher was used to polish the capsule, and viscoat was injected inflating the capsular bag and chamber.  the wound was enlarged with a shortcut blade to 5.5 mm.  the intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag.  the lens centralized nicely and viscoat was removed using the i&a.  balanced salt was injected through the side-port incision.  the wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera.  the conjunctiva was pulled over the suture, and ancef 50 mg and decadron 4 mg were injected sub-tenon in the inferonasal and inferotemporal quadrants.  maxitrol ointment was applied topically followed by an eye pad and shield.  the patient tolerated the procedure and was taken from the operating room in good condition.",25
"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.",37
"chief complaint:, this 61-year-old male presents today with recent finding of abnormal serum psa of 16 ng/ml. associated signs and symptoms: associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow.  timing (onset/frequency): onset was 6 months ago. patient denies fever and chills and denies flank pain.,allergies: ,patient admits allergies to adhesive tape resulting in severe rash. patient denies an allergy to anesthesia.,medication history:, patient is not currently taking any medications.,past medical history:, childhood illnesses: (+) asthma, cardiovascular hx: (-) angina, renal / urinary hx: (-) kidney problems.,past surgical history:, patient admits past surgical history of appendectomy in 1992.,social history:, patient admits alcohol use, drinking is described as heavy, patient denies illegal drug use, patient denies std history, patient denies tobacco use.,family history:, patient admits a family history of gout attacks associated with father.,review of systems:, unremarkable with exception of chief complaint.,physical exam: ,bp sitting: 120/80 resp: 20 hr: 72 temp: 98.6,the patient is a pleasant, 61-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.,neck: neck is normal and symmetrical, without swelling or tenderness. thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,respiratory: respirations are even without use of accessory muscles and no intercostal retractions noted. breathing is not labored, diaphragmatic, or abdominal. lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,cardiovascular: normal s1 and s2 without murmurs, gallop, rubs or clicks.  peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,gastrointestinal: abdominal organs, bladder, kidney: no abnormalities, without masses, tenderness, or rigidity. hernia: absent; no inguinal, femoral, or ventral hernias noted. liver and/or spleen: no abnormalities, tenderness, or masses noted. stool specimen not indicated.,genitourinary: anus and perineum: no abnormalities. no fissures, edema, dimples, or tenderness noted.,scrotum: no abnormalities. no lesions, rash, or sebaceous cyst noted.,epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,urethral meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,penis: no abnormalities; circumcised; no phimosis, peyronie's, condylomata, or lumps noted.,prostate: size 60 gr, rt>lt and firm.,seminal vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,skin/extremities: skin is warm and dry with normal turgor and there is no icterus. no skin rash, subcutaneous nodules, lesions or ulcers observed.,neurological/psychiatric: oriented to person, place and time. mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,test results:, no tests to report at this time.,impression: ,elevated prostate specific antigen (psa).,plan:, cystoscopy in the office.,diagnostic & lab orders:, ordered serum creatinine. urinalysis and c & s ordered using clean-catch specimen. ordered free prostate specific antigen (psa). ordered ultrasound of prostate.,i have discussed the findings of this follow-up evaluation with the patient. the discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. discussed the possibility of a turp surgical procedure; risks, complications, benefits, and alternative measures discussed. there are no activity restrictions . instructed ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. questions answered. if any questions should arise after returning home i have encouraged the patient to feel free to call the office at 327-8850.,prescriptions: , proscar dosage: 5 mg tablet sig: once daily dispense: 30 refills: 0 allow generic: no,patient instructions:,  patient completed benign prostatic hypertrophy questionnaire.",5
"reason for visit: , mr. abc is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea.  he returns today to review his response to cpap.,history of present illness: , the patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner.  he was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal cpap at 10 cm h2o nasal pressure.  he has been on cpap now for several months, and returns for followup to review his response to treatment.,the patient reports that the cpap has limited his snoring at night.  occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask.  the patient estimates that he uses the cpap approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,the patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays.  on weekends, he might sleep until 8 to 9 a.m.  on saturday night, he might go to bed approximately mid night.,as noted, the patient is not snoring on cpap.  he denies much tossing and turning and does not awaken with the sheets in disarray.  he awakens feeling relatively refreshed.,in the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,he continues to work at smith barney in downtown baltimore.  he generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m.  he is involved in training purpose to how to sell managed funds and accounts.,the patient reports no change in daytime stamina.  he has no difficulty staying awake during the daytime or evening hours.,the past medical history is notable for allergic rhinitis.,medications: , he is maintained on flonase and denies much in the way of nasal symptoms.,allergies: , molds.,findings:  ,vital signs:  blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and sao2 is 99% on room air at rest.,the patient has adenoidal facies as noted previously.,laboratories:  the patient forgot to bring his smart card in for downloading today.,assessment: , moderate-to-severe sleep apnea.  i have recommended the patient continue cpap indefinitely.  he will be sending me his smart card for downloading to determine his cpap usage pattern.  in addition, he will continue efforts to maintain his weight at current levels or below.  should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a cpap.,plans: , in the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea.  i have recommended that a fiberoptic ent exam be performed to exclude adenoidal tissue that may be contributing to obstruction.  he will be returning for routine followup in 6 months.",34
"procedure:, endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,indication for the procedure:, patient with a history of chronic abdominal pain and ct showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,medications:, general anesthesia.,the risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ercp pancreatitis.,description of procedure: ,after informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. the scope was then advanced through the pylorus to the ampulla. the ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. it extended outward with an almost polypoid shape. it had what appeared to be adenomatous-appearing mucosa on the tip. there also was ulceration noted on the tip of this ampulla. the biliary and pancreatic orifices were identified. this was located not at the tip of the ampulla, but rather more towards the base. cannulation was performed with a wilson-cooke tritome sphincterotome with easy cannulation of the biliary tree. the common bile duct was mildly dilated, measuring approximately 12 mm. the intrahepatic ducts were minimally dilated. there were no filling defects identified. there was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. the patient has no evidence of obstruction based on lab work and clinically. nevertheless, it was decided to proceed with brush cytology of this segment. this was done without any complications. there was adequate drainage of the biliary tree noted throughout the procedure. multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. efforts were made to proceed in a long scope position, but still were unsuccessful. next, biopsies were obtained of the ampulla away from the biliary orifice. four biopsies were taken. there was some minor oozing which had ceased by the end of the procedure. the stomach was then decompressed and the endoscope was withdrawn.,findings:,1. abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal cbd stricture, although i think this is likely an anatomic variant; brush cytology obtained.,3. unable to access the pancreatic duct.,recommendations:,1. npo except ice chips today.,2. will proceed with mrcp to better delineate pancreatic ductal anatomy.,3. follow up biopsies and cytology.",14
"preoperative diagnosis:,  left inguinal hernia.,postoperative diagnosis: , left inguinal hernia.,anesthesia:,  general; 0.25% marcaine at trocar sites.,name of operation:,  laparoscopic left inguinal hernia repair.,procedure: , a skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly.  the rectus muscle was retracted laterally.  balloon dissector was passed below the muscle and above the peritoneum.  insufflation and deinsufflation were done with the balloon removed.  the structural balloon was placed in the preperitoneal space and insufflated to 10 mmhg carbon dioxide.  the other trocars were placed in the lower midline times two.  the hernia sac was easily identified and was well defined.  it was dissected off the cord anteromedially.  it was an indirect sac.  it was taken back down and reduced into the peritoneal cavity.  mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place.  after this was completed, there was good hemostasis.  the cord, structures, and vas were left intact.  the trocars were removed.  the wounds were closed with 0 vicryl for the fascia, 4-0 for the skin.  steri-strips were applied.  the patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.",37
"preoperative diagnosis: , recurrent degenerative spondylolisthesis and stenosis at l4-5 and l5-s1 with l3 compression fracture adjacent to an instrumented fusion from t11 through l2 with hardware malfunction distal at the l2 end of the hardware fixation.,postoperative diagnosis: , recurrent degenerative spondylolisthesis and stenosis at l4-5 and l5-s1 with l3 compression fracture adjacent to an instrumented fusion from t11 through l2 with hardware malfunction distal at the l2 end of the hardware fixation.,procedure: , lumbar re-exploration for removal of fractured internal fixation plate from t11 through l2 followed by a repositioning of the l2 pedicle screws and evaluation of the fusion from t11 through l2 followed by a bilateral hemilaminectomy and diskectomy for decompression at l4-5 and l5-s1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the capstone system at l4-5 and l5-s1 followed by placement of the pedicle screw fixation devices at l3, l4, l5, and s1 and insertion of a 20 cm fixation plate that range from the t11 through s1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at l1-2 and then at l3-l4, l4-l5, and l5-s1 bilaterally.,description of procedure:  ,this is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from t11 through l2.  she subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  there was no evidence of infection on the imaging or with her laboratory studies.  in addition, she developed a pretty profound stenosis at l4-l5 and l5-s1 that appeared to be recurrent as well.  she now presents for revision of her hardware, extension of fusion, and decompression.,the patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  she was placed on the operative table in the prone position.  back was prepared with betadine, iodine, and alcohol.  we elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  the locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  after these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  we then dressed the l4-l5 and l5-s1 levels which were profoundly stenotic.  this was a combination of scar and overgrown bone.  she had previously undergone bilateral hemilaminectomies at l4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  after completing this, we inserted the capstone interbody spacer filled with morselized autograft bone and some bmp sponge into the disk space at both levels.  we used 10 x 32 mm spacers at both l4-l5 and l5-s1.  this corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of l4, l5 and s1 tightened the pedicle screws in l3.  this allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from s1 up to the t11 level.  once we placed the plate onto the screws and locked them in position, we then packed the remaining bmp sponge and morselized autograft bone through the plate around the incomplete fracture healing at the l1 level and then dorsolaterally at l4-l5 and l5-s1 and l3-l4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  the wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  prior to closing the skin, we confirmed correct sponge and needle count.  we placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  the cell saver blood was recycled and she was given two units of packed red blood cells as well.  i was present for and performed the entire procedure myself or supervised.",37
"chief complaint: , decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,history of present illness:,  the patient is a 45-year-old white male who was admitted with acute back pain.  the patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  on 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  he was seen at abcd hospital emergency room, was evaluated and admitted.  he was treated with iv analgesics as well as decadron, after being evaluated by dr. a.  it was decided that the patient could benefit from physical therapy, since he was unable to perform adls, and was transferred to tcu at st. joseph health services on 08/30/2007.  he had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  the patient reports that he has had a "" bulging disk"" for approximately 1 year.  he reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  the bone scan was done at xyz hospital, ordered by dr. b, the patient's oncologist.,allergies: , penicillin, amoxicillin, cephalosporin, doxycycline, ivp dye, iodine, and sulfa, all cause hives.,additionally, the patient reports that he has hives when he comes in contact with sap from the mango tree, and therefore, he avoids any mango product at all.,past medical history: , status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, gerd, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,family history:,  noncontributory.,social history: , the patient is employed in the finance department.  he is a nonsmoker.  he does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  he denies any iv drug use or abuse.,review of systems: , no chills, fever, shakes or tremors.  denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  the patient reports that his last bowel movement was on 08/30/2007.  no urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  the patient does report that he has occasional intermittent ""numbness and tingling"" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  he denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,physical examination:,vital signs:  at the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% o2 saturation on room air.  the patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,general:  the patient appears to be comfortable, in no acute distress.,heent:  normocephalic.  sclerae are nonicteric.  eomi.  tongue is at midline and no evidence of thrush.,neck:  trachea is at the midline.,lymphatics:  no cervical or axillary nodes palpable.,lungs:  clear to auscultation bilaterally.,heart:  regular rate and rhythm.  normal s1 and s2.,abdomen:  obese, softly protuberant, and nontender.,extremities:  there is no clubbing, cyanosis or edema.  there is no calf tenderness bilaterally.  bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  the right lower extremity is 4-5/5.,mental status:  he is alert and oriented.  he was pleasant and cooperative during the examination.,assessment:,1.  acute on chronic back pain.  the patient is admitted to the tcu at st. joseph health services for rehabilitation therapy.  he will be seen in consultation by physical therapy and occupational therapy.  he will continue a tapering dose of decadron over the next 10 to 14 days and a tapering schedule has been provided, also percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  status post right orchiectomy secondary to testicular cancer, stable at this time.  we will attempt to obtain copy of the most recent bone scan performed at xyz hospital ordered by dr. b.,3.  gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and protonix 40 mg daily.,4.  deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  obesity.  as mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.",26
"preoperative diagnosis:,  bunion, right foot.,postoperative diagnosis:,  bunion, right foot.,procedure performed:,  austin/akin bunionectomy, right foot.,history: , this 77-year-old african-american female presents to abcd general hospital with the above chief complaint.  the patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful.  the patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.,procedure details:,  an iv was instituted by department of anesthesia in the preop holding area.  the patient was transported to the operating room and placed on the operating table in the supine position with a safety strap across her lap.  copious amounts of webril were placed around the right ankle followed by blood pressure cuff.  after adequate sedation by the department of anesthesia, a total of 15 cc of 1:1 mixture of 1% lidocaine plain and 0.5% marcaine plain was injected in a mayo block type fashion.  the foot was then prepped and draped in the usual sterile orthopedic fashion.  the foot was elevated to the operating table and exsanguinated with an esmarch bandage.  the pneumatic ankle tourniquet was inflated to 250 mmhg.  the foot was lowered to the operating field and the stockinet was reflected.  the foot was cleansed with wet and dry sponge.,attention was directed to the bunion deformity on the right foot.  an approximately 6 cm dorsal medial incision was created over the first metatarsophalangeal joint.  the incision was then deepened with a #15 blade.  all vessels encountered were ligated with hemostasis.  the skin and subcutaneous tissue were then undermined off of the capsule medially.  a dorsal linear capsular incision was then created over the first metatarsophalangeal joint.  the periosteum and capsule were then reflected off of the first metatarsal.  there was noted to be a prominent medial eminence.  the articular cartilage was healthy for patient's age and race.  attention was then directed to the first interspace where a lateral release was performed..  a combination of sharp and blunt dissection was carried out until the adductor tendon insertions were identified.  the adductor tendons were transected as well as a lateral capsulotomy was performed.  the extensor digitorum brevis tendon was identified and transected.  care was taken to preserve the extensor hallucis longus to make sure that tendon that was transected was the extensor hallucis brevis at the _______ digitorum.  extensor hallucis brevis tendon was transected and care was taken to preserve the extensor halucis longus tendon.  attention was then directed to medial eminence, which was resected with a sagittal saw.  sagittal was then used to create a long dorsal arm outside the austin type osteotomy and the first metatarsal.  the head of the first metatarsal was then translocated laterally until correction of the intermetatarsal angle was noted.  the head was intact.  a 0.45 k-wire was inserted through subcutaneously from proximal medial to distal lateral.  a second k-wire was then inserted from distal lateral to proximal plantar medial.  adequate fixation was noted at the osteotomy site.  the k-wires were bent, cut, and pin caps were placed.  attention was then directed to the proximal phalanx of the hallux.  the capsular periostem was reflected off of the base of the proximal phalanx.  a sagittal was then used to create an akin osteotomy closing wedge.  the apex was lateral and the base of the wedge was medial.  the wedge was removed in the total and the osteotomy site was then feathered until closure was achieved without compression.  two 0.45 k-wires were then inserted, one from distal medial to proximal lateral and the second from distal lateral to proximal medial across the osteotomy site.  adequate fixation was noted at the osteotomy site and the osteotomy was closed.  the toe was noted to be in a markedly more rectus position.  sagittal saw was then used to resect the remaining prominent medial eminence.  the area was then smoothed with a reciprocating rasp.  there was noted to be a small osteophytic formation laterally over first metatarsal head that was removed with a rongeur and smoothed with a reciprocating rasp.  the area was then inspected for any remaining short bony edges, none were noted.,copious amounts of sterile saline was then used to flush the surgical site.  the capsule was closed with #3-0 vicryl.  subcutaneous closure was performed with #4-0 vicryl followed by running subcuticular #5-0 vicryl.  steri-strips were applied and 1 cc of dexamethasone phosphate was injected into the surgical site.,dressings consisted of #0-1 silk, copious betadine, 4 x 4s, kling, kerlix, and coban.  the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the right foot.  a _______ cast was then applied postoperatively.  the patient tolerated the above procedure and anesthesia well without complications.  the patient was transported from the operating room to the pacu with vital signs stable and vascular status intact to the right foot.  the patient was given postoperative pain prescription for tylenol #3 and instructed to take one q4-6h. p.o. p.r.n. for pain.  the patient is to follow up with dr. x in his office as directed.",37
"history of present illness:  ,this is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain.  at the time of my exam, he states that his left lower extremity pain has improved considerably.  he apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably.  he does have a history of multiple medical problems including atrial fibrillation, he is on coumadin, which is currently subtherapeutic, multiple cvas in the past, peripheral vascular disease, and congestive heart failure.  he has multiple chronic history of previous ischemia of his large bowel in the past.,physical exam,vital signs:  currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,heent:  unremarkable.,lungs:  clear.,cardiovascular:  an irregular rhythm.,abdomen:  soft.,extremities:  his upper extremities are well perfused.  he has palpable radial and femoral pulses.  he does not have any palpable pedal pulses in either right or left lower extremity.  he does have reasonable capillary refill in both feet.  he has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm.  apparently, this was lot worst few hours ago.  he describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,impression and plan: , this gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent.  he currently has a viable extremity and viable foot, but certainly has significant making compromised flow.  it is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention.  he certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime.  given his potential history of recent lower gi bleeding, he has been evaluated by gi to see whether or not he is a candidate for heparinization.  we will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate.  again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity.  we will follow him along closely.",5
"reason for visit:  ,followup 4 months status post percutaneous screw fixation of a right schatzker iv tibial plateau fracture and second through fifth metatarsal head fractures treated nonoperatively.,history of present illness:  ,the patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of schatzker iv tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures.  he is currently at home and has left nursing home facility.  he states that his pain is well controlled.  he has been working with physical therapy two to three times a week.  he has had no drainage or fever.  he has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy.,findings: , on physical exam, his incision is near well healed.  he has no effusion noted.  his range of motion is 10 to 105 degrees.  he has no pain or crepitance.  on examination of his right foot, he is nontender to palpation of the metatarsal heads.  he has 4 out of 5 strength in ehl, fhl, tibialis, and gastroc-soleus complex.  he does have decreased sensation to light touch in the l4-l5 distribution of his feet bilaterally.,x-rays taken including ap and lateral of the right knee demonstrate a healed medial tibial plateau fracture status post percutaneous screw fixation.  examination of three views of the right foot demonstrates the second through fifth metatarsal head fractures.  these appear to be extraarticular.  they are all in a bayonet arrangement, but there appears to be bridging callus between the fragments on the oblique film.,assessment:  ,four months status post percutaneous screw fixation of the right medial tibial plateau and second through fifth metatarsal head fractures.,plans: , i would like the patient to continue working with physical therapy.  he may be weightbearing as tolerated on his right side.  i would like him to try to continue to work to gain full extension of the right knee and increase his knee flexion.  i also would like him to work on ambulation and strengthening.,i discussed with the patient his concerning symptoms of paresthesias.  he said he has had the left thigh for a number of years and has been followed by a neurologist for this.  he states that he has had some right-sided paresthesias now for a number of weeks.  he claims he has no other symptoms of any worsening stenosis.  i told him that i would see his neurologist for evaluation or possibly a spinal surgeon if his symptoms progress.,the patient should follow up in 2 months at which time he should have ap and lateral of the right knee and three views of the right foot.",26
"subjective:,  the patient states that he feels sick and weak.,physical examination:,vital signs:  highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,general:  the patient looks tired.,heent:  oral mucosa is dry.,chest:  clear to auscultation.  he states that he has a mild cough, not productive.,cardiovascular:  first and second heart sounds were heard.  no murmur was appreciated.,abdomen:  soft and nontender.  bowel sounds are positive. murphy's sign is negative.,extremities:  there is no swelling.,neuro:  the patient is alert and oriented x 3.  examination is nonfocal.,laboratory data: , white count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  glucose is in the low 100s.  comprehensive metabolic panel is unremarkable.  ua is negative for infection.,assessment and plan:,1.  fever of undetermined origin, probably viral since white count is normal.  would continue current antibiotics empirically.,2.  dehydration.  hydrate the patient.,3.  prostatic hypertrophy.  urologist, dr. x.,4.  dvt prophylaxis with subcutaneous heparin.",15
"preoperative diagnosis:,1.  anal cancer.,2.  need for iv access.,postoperative diagnosis:,1.  anal cancer.,2.  need for iv access.,operative procedure:,1.  placement of a port-a-cath.,2.  fluoroscopic guidance.,anesthesia:,  general lma.,estimated blood loss:,  minimum.,iv fluids: , per anesthesia.,recurrent complications: , none.,findings: , good port placement on c-arm.,indications and procedure in detail: , this is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs iv access for chemotherapy.  risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed.  the patient was taken to the operating room, placed in supine position.  general lma anesthesia was administered.  she is prepped and draped in the usual sterile fashion.  she was placed in the trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire.  fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava.  the incision was then made around the guide wire, taken to the subcutaneous tissues with electric bovie cautery.  a pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements.  the 2-0 vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a port catheter being placed into the sheath introducer.  fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 vicryl followed by running 4-0 vicryl subcuticular stitch.  heparin flush was used to flush the port.  steri-strips were applied and the patient was awakened and extubated in the or taken to the pacu in good condition.  all counts were reported as correct and i was present for the entire procedure.",37
"exam:,mri right shoulder,clinical:, a 32-year-old male with shoulder pain.,findings:,this is a second opinion interpretation of the examination performed on 02/16/06.,normal supraspinatus tendon without surface fraying, gap or fiber retraction and there is no muscular atrophy.,normal infraspinatus and subscapularis tendons.,normal long biceps tendon within the bicipital groove. there is no subluxation of the tendon under the transverse humeral ligament and the intracapsular portion of the tendon is normal.,normal humeral head without fracture or subluxation.,there is myxoid degeneration within the superior labrum (oblique coronal images #47-48), but there is no discrete tear. the remaining portions of the labrum are normal without osseous bankart lesion.,normal superior, middle and inferior glenohumeral ligaments.,there is a persistent os acromiale, and there is minimal reactive marrow edema on both sides of the synchondrosis, suggesting that there may be instability (axial images #3 and 4). there is no diastasis of the acromioclavicular joint itself. there is mild narrowing of the subacromial space secondary to the os acromiale, in the appropriate clinical setting, this may be acting as an impinging lesion (sagittal images #56-59).,normal coracoacromial, coracohumeral and coracoclavicular ligaments.,there are no effusions or masses.,impression:,changes in the superior labrum compatible with degeneration without a discrete surfacing tear.,there is a persistent os acromiale, and there is reactive marrow edema on both sides of the synchondrosis suggesting instability. there is also mild narrowing of the subacromial space secondary to the os acromiale. this may be acting as an impinging lesion in the appropriate clinical setting.,there is no evidence of a rotator cuff tear.",26
"reason for referral: , the patient was referred to me by dr. x of the hospitalist service at children's hospital due to a recent admission for pseudoseizures.  this was a 90-minute initial intake completed on 10/19/2007 with the patient's mother.  i have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,presenting problem: , it is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity.  these were confirmed by video eeg and consist of trembling, shaking, and things of that nature.  she does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality.  i had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart.  it was reported to me that she has been under considerable stress.  first of all, it should be noted that the patient is developmentally delayed.  although she is 17 years old, she operates at about a fourth grade level.  mother reported that the patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset.  it is reported, the patient feels that her mother yells at her, and that is mad at her often.  it was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison.  she reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school.  she reports that she has no friends that she feels unwanted and picked on.  she gets confused easily at school, worries about things, and believes that the teachers become angry with her.  in regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her.  she sits in the couch, she become angry, does not speak.  mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes.  it is reported that the patient has ""always been this way"" and that is not a change in her behavior.  mother did think that she did seem a little more depressed, that she seems more lonely.  over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored.  mother reported that she frequently complains of being bored, but has always been this way.  no sleep disturbance was noted.  no changes in weight.  no suicidal ideation.  no deficits in energy were noted.  mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,developmental history:,  the patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery.  she was delivered at 36 weeks' gestation.  mother reported that she received prenatal care.  difficulties during the pregnancy were denied.  the use of drugs, alcohol, tobacco during the pregnancy were denied.  no eating or sleeping difficulties during the perinatal period were reported.  temperament was described as easy.  the patient is described as a cuddly baby.  in terms of serious injuries, they were denied.  serious illnesses:  she has been diagnosed since age 5 with seizures.  mother was not able to tell me the exact kind of seizures, but it would appear from i could gather that they are focal seizures and possibly simple-to-complex partial seizures.  the patient does not have a history of allergy or toileting problems.  she is currently taking trileptal 450 mg b.i.d., and she is currently taking depakote, although she is going to be weaned off the depakote by her neurologist.  she is taking prevacid and ibuprofen.  the neurologist that she sees is dr. y here at children's hospital.,family background:,  in terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays.  mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the abc area and visits them every other saturday, but there are no overnight visits.  the paternal grandparents are both living here in california, but are separated.  they are 3 paternal uncles and 2 paternal aunts.  in terms of the maternal family, maternal grandmother and grandfather are deceased.  maternal grandfather deceased in 1991 due to cancer.  maternal grandmother deceased in 2001 due to cancer.  there are 5 maternal aunts and 2 maternal uncles, all who live in california.  she reported that the patient is particularly close to her maternal aunt, whose name is carmen.  mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life.  in terms of other family background, it was reported that the mother's partner gets frustrated with the patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things.  the sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does.  the biological father allegedly was in jail for a year due to drug possession.  mother reported that he had a problem with methamphetamine.  in addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that.  she stated there was no evidence that he had ever molested the patient or her sister.  there had been quite a bit of chaos in the family when the mother and father were together.  there was a lot of arguing.  there were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report.  the patient did observe this.  after the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them.  mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail.  mother stated that was approximately 5 years ago.  in terms of current, mother reports that she currently works 2 jobs from 8 to 5 on monday and friday and from 6 to 10 on monday, wednesday's, and friday's, but she does have the weekends off.  the patient was reported also to have a job through her school on several weeknights.,mother reported that she graduated from high school, had a year of college.  she was an average student, had learning difficulties in reading.  no psychological or drug or alcohol history was reported by mother.  in terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported.  mother reported that he had a history of methamphetamine use.,other psychiatric history in the family was denied.,social history: , she reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun.  her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that.  it was reported that she really feels that she is bored and does not have much to do.,academic background:  ,the patient is in the 11th grade at high school.  she has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education.  mother could not tell me what her iq was, although she noticed she works at about a 4th or 5th grade level.  mother reported that the terminology most often used with the patient was developmental delay.  her counselor's name is mr. xyz, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand.  it is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school.  she reported that the patient is involved in a work program through the school where she works at pet extreme on mondays and wednesdays from 3 to 8 p.m. where she stocks shelves.  it is reported that she does not like to go to school because she feels like nobody likes her.  she is not involved in any kind of clubs or groups at school.  mother reported that she is also not receiving cvrc services.,previous counseling: , mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about.  she does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,diagnostic summary and impression:,  it appears that the patient best qualifies for a diagnosis of conversion disorder, and information from neurology suggests that the ""seizure episodes"" are not true seizures, but appear to be pseudoseizures.  the patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,plan:,  my plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,dsm iv diagnoses:  ,axis i:  conversion disorder (300.11).,axis ii:  diagnoses deferred.,axis iii:  seizure disorder.,axis iv:  problems with primary support group, peer problems, and educational problems.,axis v:  global assessment of functioning equals 60.",5
"preoperative diagnoses,1.  acute coronary artery syndrome with st segment elevation in anterior wall distribution.,2.  documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  he is intubated and ventilated.,postoperative diagnoses:,  acute coronary artery syndrome with st segment elevation in anterior wall distribution.  primary ventricular arrhythmia.  occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,procedures:,  left heart catheterization, selective bilateral coronary angiography and left ventriculography.  revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  right heart catheterization and swan-ganz catheter placement for monitoring.,description of procedure:  ,the patient arrived from the emergency room intubated and ventilated.  he is hemodynamically stable on heparin and integrilin bolus and infusion was initiated.  the right femoral area was prepped and draped in usual sterile fashion.  lidocaine 2 ml was then filled locally.  the right femoral artery was cannulated with an 18-guage needle followed by a 6-french vascular sheath.  a guiding catheter xb 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  a confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  an angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  an angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  it successfully re-canalized the artery.  there is evidence of residual stenosis within the distal aspect of the previous stents.  a drug-eluting stent xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  the intermittent result was improved.  an additional inflation was obtained more proximally.  his blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  there is patency of the left anterior descending artery and good antegrade flow.  the guiding catheter was replaced with a 5-french judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  the catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  the right femoral vein was cannulated with an 18-guage needle followed by an 8-french vascular sheath.  a 8-french swan-ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  cardiac catheter was determined by thermal dilution.  the procedure was then concluded, well tolerated and without complications.  the vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  fluoroscopy time was 8.2 minutes.  total amount of contrast was 113 ml.,hemodynamics:,  the patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  his initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmhg.  there was no gradient across the aortic valve.  closing pressure was 97/68 with a mean of 82.,right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  cardiac output was 5.87 by thermal dilution.,coronaries:,  on fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,a.  left main coronary:  the left main coronary artery is of good caliber and has no evidence of obstructive lesions.,b.  left anterior descending artery:  the left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  there is minimal collateral flow.,c.  circumflex:  circumflex is a nondominant circulation.  it supplies a first obtuse marginal branch on good caliber.  there is an outline of the stent in the midportion, which has mild 30% stenosis.  the rest of the vessel has no significant obstructive lesions.  it also supplies significant collaterals supplying the occluded right coronary artery.,d.  right coronary artery:  the right coronary artery is a weekly dominant circulation.  the vessel is occluded in intermittent portion and has a minimal collateral flow distally.,angioplasty: , the left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  the stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  there is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  the distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  there is good antegrade flow and no evidence of distal embolization.,conclusion: , acute coronary artery syndrome with st-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,acute coronary artery syndrome with st-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  there is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,right femoral arterial and venous vascular access.,recommendation:,  integrilin infusion is maintained until tomorrow.  he received aspirin and plavix per nasogastric tube.  titrated doses of beta-blockers and ace inhibitors are initiated.  additional revascularization therapy will be adjusted according to the clinical evaluation.",3
"admission diagnosis:,  end-stage renal disease (esrd).,discharge diagnosis: , end-stage renal disease (esrd).,procedure:,  cadaveric renal transplant.,history of present illness: , this is a 46-year-old gentleman with end-stage renal disease (esrd) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,past medical history:  ,1.  diabetes mellitus diagnosed 12 years ago.,2.  hypertension.,3.  coronary artery disease with a myocardial infarct in september of 2006.,4.  end-stage renal disease.,past surgical history: , coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,social history:  ,the patient denies tobacco or ethanol use.,family history:,  hypertension.,physical examination:  ,general:  the patient was alert and oriented x3 in no acute distress, healthy-appearing male.,vital signs:  temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,cardiovascular:  regular rate and rhythm.,pulmonary:  clear to auscultation bilaterally.,abdomen:  soft, nontender, and nondistended with positive bowel sounds.,extremities:  no clubbing, cyanosis, or edema.,pertinent laboratory data: , white blood cell count 6.4, hematocrit 34.6, and platelet count 182.  sodium 137, potassium 5.4, bun 41, creatinine 7.9, and glucose 295.  total protein 6.5, albumin 3.4, ast 51, alt 51, alk phos 175, and total bilirubin 0.5.,course in hospital: , the patient was admitted postoperatively to the surgical intensive care unit.  initially, the patient had a decrease in hematocrit from 30 to 25.  the patient's hematocrit stabilized at 25.  during the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  the patient was making excellent urine throughout his stay.  the patient's jackson-pratt drain was removed on postoperative day #1 and he was moved to the floor.  the patient was advanced in diet appropriately.  the patient was started on prograf by postoperative day #2.  initial prograf levels came back high at 18.  the patient's prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  during the patient's stay, the patient received four total doses of thymoglobulin.  today, he will complete his final dose of thymoglobulin prior to being discharged.  in addition, today, the patient has an elevated blood pressure of 198/96.  the patient is being given an extra dose of metoprolol for this blood pressure.  in addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  these labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,discharge instructions: , the patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  he is discharged on a low-potassium diet with activity as tolerated.  he is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  the patient will be followed up in the transplant clinic at abcd tomorrow, at which time, his labs will be rechecked.  the patient's prograf levels at the time of discharge are pending; however, given that his prograf dose was decreased, he will be followed tomorrow at the renal transplant clinic.",10
"preoperative diagnosis: , cataract, right eye.,postoperative diagnosis:  ,cataract, right eye.,procedure performed:  ,cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  an alcon ma30ba lens was used, * diopters, #*.,anesthesia: ,topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,complications:, none.,procedure: , prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  the patient understood the risks clearly and wished to proceed.,the patient was brought into the operating suite after being given dilating drops.  topical 4% lidocaine drops were used.  the patient was prepped and draped in the normal sterile fashion.  a lid speculum was placed into the right eye.  paracentesis was made at the infratemporal quadrant.  this was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  this was exchanged for viscoat solution.  next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  this was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  circular capsulorrhexis was initiated with a cystitome and completed with utrata forceps.  balanced salt solution was used to hydrodissect the nucleus.  nuclear material was removed via phacoemulsification with divide-and-conquer technique.  the residual cortex was removed via irrigation and aspiration.  the capsular bag was then filled with provisc solution.  the wound was slightly enlarged.  the lens was folded and inserted into the capsular bag.,residual provisc solution was irrigated out of the eye.  the wound was stromally hydrated and noted to be completely self-sealing.,at the end of the case, the posterior capsule was intact.  the lens was well centered in the capsular bag.  the anterior chamber was deep.  the wound was self sealed and subconjunctival injections of ancef, dexamethasone and lidocaine were given inferiorly.  maxitrol ointment was placed into the eye.  the eye was patched with a shield.,the patient was transported to the recovery room in stable condition to follow up the following morning.",25
"preoperative diagnosis: , cataract, right eye.,postoperative diagnosis:,  cataract, right eye.,procedure:,  phacoemulsification with intraocular lens placement, right eye.,anesthesia: , monitored anesthesia care,estimated blood loss: , none,complications:,  none,specimens:,  none,procedure in detail: , the patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  the patient had the risks and benefits of surgery discussed.  after discussion, the patient decided to proceed and the consent was signed.,on the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  following this, the patient was sterilely prepped and draped in the usual fashion.  after this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the supersharp blade was used to make an anterior chamber paracentesis.  preservative-free lidocaine was instilled into the anterior chamber, and then viscoat was instilled into the eye.,the 3.0 diamond keratome was then used to make a clear corneal temporal incision.  following this, the cystotome was used to make a continuous tear-type capsulotomy.  after this, bss was used to hydrodissect and hydrodelineate the lens.  the phacoemulsification unit was used to remove the cataract.  the i&a unit was used to remove the residual cortical material.  following this, provisc was used to inflate the bag.  the lens, a model sa60at of abcd diopters, serial #1234, was inserted into the bag and rotated into position using the lester pusher.,after this, the residual provisc was removed.  michol was instilled and then the corneal wound was hydrated with bss, and the wound was found to be watertight.  the lid speculum was removed.  acular and vigamox drops were placed.  the patient tolerated the procedure well without complications and will be followed up in the office tomorrow.",25
"subjective:,  grandfather brings the patient in today because of headaches, mostly in her face.  she is feeling pressure there with a lot of sniffles.  last night, she complained of sore throat and a loose cough.  over the last three days, she has had a rash on her face, back and arms.  a lot of fifth disease at school.  she says it itches and they have been doing some benadryl for this.  she has not had any wheezing lately and is not taking any ongoing medications for her asthma.,past medical history:,  asthma and allergies.,family history:  ,sister is dizzy but no other acute illnesses.,objective:,general:  the patient is an 11-year-old female.  alert and cooperative.  no acute distress.,neck:  supple without adenopathy.,heent:  ear canals clear.  tms, bilaterally, gray in color and good light reflex.  oropharynx is pink and moist.  no erythema or exudates.  she has postnasal discharge.  nares are swollen and red.  purulent discharge in the posterior turbinates.  both maxillary sinuses are tender.  she has some mild tenderness in the left frontal sinus.  eyes are puffy and she has dark circles.,chest:  respirations are regular and nonlabored.,lungs:  clear to auscultation throughout.,heart:  regular rhythm without murmur.,skin:  warm, dry and pink.  moist mucous membranes.  red, lacey rash from the wrists to the elbows, both sides.  it is very faint on the lower back and she has reddened cheeks, as well.,assessment:,  fifth disease with sinusitis.,plan:,  omnicef 300 mg daily for 10 days.  may use some zyrtec for the itching.  samples are given.",15
"procedures performed:,  phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,procedure codes: , 64640 times three, 64614 times four, 95873 times four.,preoperative diagnosis: , spastic quadriparesis secondary to traumatic brain injury, 907.0.,postoperative diagnosis:,  spastic quadriparesis secondary to traumatic brain injury, 907.0.,anesthesia:,  mac.,complications: , none.,description of technique: , informed consent was obtained from the patient's brother.  the patient was brought to the minor procedure area and sedated per their protocol.  the patient was positioned lying supine.  skin overlying all areas injected was prepped with chlorhexidine.  the obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active emg stimulation.  approximately 7 ml was injected on the right side and 5 ml on the left side.  at all sites of phenol injections in this area 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.  the musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active emg stimulation.  approximately 5 ml of 5% phenol was injected in this location.  injections in this area were done at the site of maximum elbow flexion 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 using active emg stimulation.  approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  total amount of botulinum toxin injected was 450 units diluted 25 units to 1 ml.  the patient tolerated the procedure well and no complications were encountered.",37
"subjective:,  the patient is here for a follow-up.  the patient has a history of lupus, currently on plaquenil 200-mg b.i.d.  eye report was noted and appreciated.  the patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  she denied having any trauma.  she states that the pain is bothering her.  she denies having any fevers, chills, or any joint effusion or swelling at this point.  she noted also that there is some increase in her hair loss in the recent times.,objective:,  the patient is alert and oriented.  general physical exam is unremarkable.  musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  hand examination is unremarkable today.  the rest of the musculoskeletal exam is unremarkable.,assessment:,  epicondylitis, both elbows, possibly secondary to lupus flare-up.,plan:,  we will inject both elbows with 40-mg of kenalog mixed with 1 cc of lidocaine.  the posterior approach was chosen under sterile conditions.  the patient tolerated both procedures well.  i will obtain cbc and urinalysis today.  if the patient's pain does not improve, i will consider adding methotrexate to her therapy.,sample doctor m.d.",34
"preoperative diagnosis: , metopic synostosis with trigonocephaly.,postoperative diagnosis: , metopic synostosis with trigonocephaly.,procedures performed: , ,1.  bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with z-osteotomies.,2.  bone grafts.,3.  bilateral forehead reconstruction with autologous graft.,anesthesia: , general endotracheal anesthesia.,complications:,  none.,condition of the patient at the end of the procedure: , stable, transferred to recovery room.,estimated blood loss: , 300 ml.,crystalloids: , packed red blood cells 440 ml, ffp 100 ml.,urinary output: , 160 ml.,indications for procedure: , the patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  we have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  we have discussed risks and benefits.  risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  the parents understand, decide to proceed with surgery.  informed consent was obtained and we proceed with surgery.,description of procedure: , the patient was taken into the operating room, placed in the supine position.  general anesthetic was administered.  prophylactic dose of antibiotic was given.  lines were placed by anesthesia and then the head of the bed was turned to 100 degrees.  the patient was once more positioned and padded in the usual manner.  the incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,the procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  the subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  hemostasis achieved with electrocautery.  raney clips were applied to both flaps to prevent significant bleeding.  then, we proceed with craniotomy part and dr. y proceeded with this part of the procedure.  i assisted her and this will be described in a different operative report.  then, the area corresponding to the c-shaped osteotomy was marked and then we proceed in conjunction with dr. y to develop these osteotomies with the help of the midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  the osteotomies were done with the midas and some irrigation.  there was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  this was done on both sides.  hemostasis achieved with bone wax and electrocautery.  once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  on the left side, there was a minor fracture to the superior orbital rim that was plated.  the bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  the temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with midas and a 3-0 vicryl interrupted stitches.  the forehead flaps were attached with the help of absorbable mesh.  the forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of synthes mesh and 3-mm screws.  hemostasis was checked.  the flaps were retracted back into position.,the wound was closed with 3-0 vicryl interrupted sutures, 4-0 vicryl interrupted stitches, and 5-0 running fast absorbing gut.  dressing was applied with xeroform, bacitracin, and abds and a burn net.  the patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  i was present and participated in all aspects of the procedure.  sponge, needle, and instrument counts were completed at the end of the procedure.",6
"ct head without contrast, ct facial bones without contrast, and ct cervical spine without contrast,reason for exam: , motor vehicle collision.,ct head,technique: , noncontrast axial ct images of the head were obtained without contrast.,findings: , there is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  the ventricles and cortical sulci are normal in shape and configuration.  the gray/white matter junctions are well preserved.  no calvarial fracture is seen.,impression:  ,negative for acute intracranial disease.,ct facial bones without contrast,technique:  ,noncontrast axial ct images of the facial bones were obtained with coronal reconstructions.,findings:,  there is no facial bone fracture.  the maxilla and mandible are intact.  the visualized paranasal sinuses are clear.  the temporomandibular joints are intact.  the nasal bone is intact.  the orbits are intact.  the extra-ocular muscles and orbital nerves are normal.  the orbital globes are normal.,impression: , no evidence for a facial bone fracture.,ct cervical spine without contrast,technique: , noncontrast axial ct images of the cervical spine were obtained with sagittal and coronal reconstructions.,findings: , there is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  the vertebral body heights are normal.  the intervertebral disk spaces are well preserved.  the atlanto-dens interval is normal.  no abnormal anterior cervical soft tissue swelling is seen.  there is no spinal compression deformity.,impression: , negative for a facial bone fracture.",32
"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.,",21
"reason for consultation: , lethargy.,history of present illness:,  the patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for pe, dvt, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  symptoms began on february 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  the patient's appetite is unknown since she had been fed by ng tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  prior to receiving the news for needing more cancer therapy, the patient was described as being ""fine,"" participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  has been on a daily dose of lexapro since january 08, 2007, was increased from 10 mg to 20 mg on january 24, 2007, which is her current dose.  has been on provigil 100 mg b.i.d. since february 06, 2007, but has not noticed an impact.  had been on zyprexa 2.5 mg p.o. q.p.m. from december 20, 2006, to february 01, 2007, but has been discontinued.  currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  also, denies any homicidal ideations.,past psychiatric history:,  was prescribed prozac for depression, felt during husband's successful battle with prostate cancer.  never been diagnosed with psychiatric illness.  displayed some psychotic symptoms, status post craniotomy while in icu, treated with zyprexa and xanax during hospitalization in 2006.,past medical history:,  craniotomy november 2006 with subsequent csf infection of enterobacter, status post glioblastoma multiforme, pe, dvt, hypertension, siadh, and ivc filter.  no history of thyroid problems, seizures, strokes, or traumatic head injuries.,home medications:,  norvasc 5 mg daily, tricor 145 mg daily, aspirin one tablet daily, tylenol, and glucosamine chondroitin sulfate.,current medications:,  norvasc 10 mg p.o. daily, decadron injection 6 mg iv q.12h., colace 100 mg liquid b.i.d., cardura 2 mg p.o. daily, lexapro 20 mg p.o. daily, lopressor 50 mg p.o. q.12h., flagyl 500 mg via peg tube q.8h., modafinil 100 mg p.o. b.i.d., lovenox 60 mg subcu q.12h., insulin sliding scale, tylenol suppositories 650 mg rectal q.4h. p.r.n., and ambien 5 mg p.o. q.h.s. p.r.n.,allergies:,  phenytoin (stevens-johnson syndrome), codeine, novocain, unknown allergy.,family medical history:,  father had lung cancer, was smoker for 40 years.  father's aunt have heart disease.,social and developmental history:,  currently lives with husband of 40 years in league city, has a masters in education, is a retired reading specialist which she did it for 33 years.  has one younger brother, one daughter.  denies use of tobacco, alcohol and illicit drugs.  the child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,mental status examination:,  the patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  positive for passive suicidal ideations and perceptions.  no auditory or visual hallucinations.  sensorium stuporous, did not answer orientation questions.  memory information, intelligence, judgment, and insight unknown.,mini-mental status examination unable to be performed.,assessment:,  a 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent cns infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,axis i:  depression, nos.  rule out depression secondary to general medical condition.,axis ii:  deferred.,axis iii:  craniotomy with subsequent csf infection, pe, dvt, and hypertension.,axis iv:  hospitalization.,axis v:  11.,plan:,  continue lexapro 20 mg p.o. daily.  discontinue provigil, begin ritalin 5 mg p.o. q.a.m. and q. noon.,thank you for the consultation.",5
"preoperative diagnoses:,  tearing, eyelash encrustation with probable tear duct obstruction bilateral.,postoperative diagnoses:  ,1.  distal nasolacrimal duct stenosis with obstruction, left eye.,2.  distal nasolacrimal duct stenosis with obstruction, right eye.,operative procedure: , bilateral nasolacrimal probing.,anesthesia: , monitored anesthesia care along with mask sedation.,indications for surgery: , this young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  conservative measures at home have failed to completely resolve the symptoms.  he has been placed on previous antibiotics treatment for presumed conjunctivitis.  please refer to clinic note for more details.  conservative measures at home have failed to resolve the symptoms.  a nasolacrimal probing was offered as an elective procedure.  procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  the risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  also a rare possibility of errant passage of the nasolacrimal probe was discussed.  preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  no guarantees were offered.  informed consent was signed and placed on the chart.,description of procedure:  ,the patient was identified and the procedure was verified.  procedure as well as inherent risks were again discussed with parents prior to the procedure.  after anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with tono-pen.  the pressure on the right was 17 mmhg and on the left was 16 mmhg.,a punctal dilator was then used to dilate the left superior puncta.  a size 00 bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  the probe was advanced until a firm stop of the lacrimal bone was felt.  the probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  a mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  there was also some mild stenosis distally, but not felt significant.  the probe was used to navigate through this mild resistance.  a second bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  both probes were removed.  the 00 bowman probe was then used to navigate the inferior puncta canaliculus system.  patency was confirmed.  the left upper lid was everted and inspected and was found to be normal.,attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  a punctal dilator was used to dilate the puncta followed by a size 00 bowman probe.  again on this side, a size 0 bowman probe was unable to be placed initially to the superior puncta.  the probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  the mild resistance was over come at the approximate location of the valve.  metal-on-metal feel confirmed patency through the right naris with a second metal probe.  at the completion of the procedure all probes were removed.  awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,postoperative instructions were provided to the parents by me, and the discharging nurse.  i did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  technique explained and demonstrated.  erythromycin ointment to both eyes twice daily for three days.  follow up was arranged and he may call with any further questions or concerns.",25
"preoperative diagnoses:,1.  urinary retention.,2.  benign prostate hypertrophy.,postoperative diagnoses:,1.  urinary retention.,2.  benign prostate hypertrophy.,procedures performed:,1.  cystourethroscopy.,2.  transurethral resection of prostate (turp).,anesthesia:,  spinal.,resection time:,  less than one hour.,indication for procedure:  ,this is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,procedure:  procedure: , informed written consent was obtained.  the patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position.  she was sterilely prepped and draped in normal fashion.  a #27-french resectoscope was inserted utilizing the visual obturator blanching the bladder.  the bladder was visualized in all quadrants, no bladder tumors or stones were noted.  ureteral orifices were visualized and did appear to be near the enlarged median lobe.  prostate showed trilobar prostatic enlargement.  there were some cellules and tuberculations noted.  the visual obturator was removed.  the resectoscope was then inserted utilizing the #26 french resectoscope loop.  resection was performed initiating at the bladder neck and at the median lobe.,this was taken down to the circular capsular fibers.  attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum.  ureteral orifices were kept out of harm's way throughout the case.  resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion.  attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way.  the resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed.  open prostatic fossa was noted.  all chips were evacuated via ellik evacuator and #24 french three-way foley catheter was inserted and irrigated.  clear return was noted.  the patient was then hooked up to better irrigation.  the patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,plan:  ,we will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.",38
"preoperative diagnosis:,  left pleural effusion.,postoperative diagnosis:,  left hemothorax.,procedure: , thoracentesis.,procedure in detail:,  after obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  his left back was prepped and draped in the usual fashion.  xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 ml blood.  this blood was nonclotting and it was tested twice.  halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  therefore, we laid him off his right side while keeping the chest catheter in place.  at that time, i proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a ct in the morning to see whether the patient would need an pigtail intrapleural catheter or not.",3
"preoperative diagnosis:,  right inguinal hernia.,postoperative diagnosis:,  right inguinal hernia.,procedure:,  right inguinal hernia repair.,indications for procedure: , this patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia.  the patient is being taken to the operating room for inguinal hernia repair.,description of procedure: , the patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  the patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion.  an incision was made in the right inguinal skin crease.  the incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring.  the hernia sac was verified and dissected at the level of the internal ring and a high ligation performed.  the distal remnant was taken to its end and excised.  the testicle and cord structures were placed back in their native positions.  the aponeurosis of the external oblique was reapproximated with 3-0 vicryl as well as the scarpa's, the skin closed with 5-0 monocryl and dressed with steri-strips.  the patient was extubated in the operating room and taken back to the recovery room.  the patient tolerated the procedure well.",38
"chief complaint:,  left knee pain.,subjective: , this is a 36-year-old white female who presents to the office today with a complaint of left knee pain.  she is approximately five days after a third synvisc injection.  she states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension.  rates her pain in her knee as a 10/10.  she does alternate ice and heat.  she is using tylenol no. 3 p.r.n. and ibuprofen otc p.r.n. with minimal relief.,allergies,1.  penicillin.,2.  keflex.,3.  bactrim.,4.  sulfa.,5.  ace bandages.,medications,1.  toprol.,2.  xanax.,3.  advair.,4.  ventolin.,5.  tylenol no.  3.,6.  advil.,review of systems:,  will be starting the medifast diet, has discussed this with her pcp, who encouraged her to have gastric bypass, but the patient would like to try this medifast diet first.  other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, gi, gu, musculoskeletal, nervous system, except what is noted above and below.,physical examination,vital signs:  pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,general:  this is a 36-year-old white female who is a&o x3, in no apparent distress with a pleasant affect.  she is well developed, well nourished, appears her stated age.,extremities:  orthopedic evaluation of the left knee reveals there to be well-healed portholes.  she does have some medial joint line swelling.  negative ballottement.  she has significant pain to palpation of the medial joint line, none of the lateral joint line.  she has no pain to palpation on the popliteal fossa.  range of motion is approximately -5 degrees to 95 degrees of flexion.  it should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right.  she has a click with mcmurray.  negative anterior-posterior drawer.  no varus or valgus instability noted.  positive patellar grind test.  calf is soft and nontender.  gait is stable and antalgic on the left.,assessment,1.  osteochondral defect, torn meniscus, left knee.,2.  obesity.,plan: , i have encouraged the patient to work on weight reduction, as this will only benefit her knee.  i did discuss treatment options at length with the patient, but i think the best plan for her would be to work on weight reduction.  she questions whether she needs a total knee; i don't believe she needs total knee replacement.  she may, however, at some point need an arthroscopy.  i have encouraged her to start formal physical therapy and a home exercise program.  will use ice or heat p.r.n.  i have given her refills on tylenol no.  3, flector patch, and relafen not to be taken with any other anti-inflammatory.  she does have some abdominal discomfort with the anti-inflammatories, was started on nexium 20 mg one p.o. daily.  she will follow up in our office in four weeks.  if she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with dr. x whether she would benefit from another knee arthroscopy.  the patient shows a good understanding of this treatment plan and agrees.",26
"chief complaint:,1.  infection.,2.  pelvic pain.,3.  mood swings.,4.  painful sex.,history of present illness:,  the patient is a 29-year-old female who is here today with the above-noted complaints.  she states that she has been having a lot of swelling and infection in her inner thigh area with the folliculitis she has had in the past.  she is requesting antibiotics.  she has been squeezing them and some of them are very bruised and irritated.  she also states that she is having significant pelvic pain and would like to go back and see dr. xyz again.  she also states that she took herself off of lithium, but she has been having significant mood swings, anger outbursts and not dealing with the situation well at all.  she also has had some psychiatric evaluation, but she states that she did not feel like herself on the medication, so she took herself off.  she states she does not wish to be on any medication at the current time.  she otherwise states that sex is so painful that she is unable to have sex with her husband, even though she ""wants to."",past medical history:,  significant for cleft palate.,allergies:,  she is allergic to lortab.,current medications:,  none.,review of systems:,  please see history of present illness.,psychiatric:  she has had some suicidal thoughts, but no plans.  she denies being suicidal at the current time.,cardiopulmonary:  she has not had any chest pain or shortness of breath.,gi:  denies any nausea or vomiting.,neurological:  no numbness, weakness or tingling.,physical examination:,general:  the patient is a well-developed, well-nourished, 29-year-old female who is in no acute distress.,vital signs:  weight:  160 pounds.  blood pressure:  100/60.  pulse:  62.,psychiatric:  i did spend over 25 minutes face-to-face with the patient talking about the situation she was in and the medication and her discontinuing use of that.,extremities:  her inner thighs are covered with multiple areas of folliculitis and mild abscesses.  they are bruised from her squeezing them.  we talked about that in detail.,assessment:,1.  folliculitis.,2.  pelvic pain.,3.  mood swings.,4.  dyspareunia.,plan:,1.  i would like her to go to the lab and get a cbc, chem-12, tsh and ua.,2.  we will put her on cephalexin 500 mg three times a day.,3.  we will send her back to see dr. xyz regarding the pelvic pain per her request.,4.  we will get her an appointment with a psychiatrist for evaluation and treatment.,5.  she is to call if she has any further problems or concerns.  otherwise i will see her back for her routine care or sooner if there are any further issues.",5
"preoperative diagnosis: , chronic cholecystitis.,postoperative diagnosis:  ,chronic cholecystitis.,procedure performed:  ,laparoscopic cholecystectomy.,blood loss: , minimal.,anesthesia: , general endotracheal anesthesia.,complications: , none.,condition: , stable.,drains: , none.,disposition:  ,to recovery room and to home.,fluids:  ,crystalloid.,findings: , consistent with chronic cholecystitis.  final pathology is pending.,indications for the procedure:  ,briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  he presented now after informed consent for the above procedure.,procedure in detail:  ,the patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  the patient was correctly positioned, padded at all pressure points, had antiembolic ted hose and flowtrons in the lower extremities.  the anterior abdomen was then prepared and draped in a sterile fashion.  preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  the initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with bovie cautery, down to the midline fascia with a #15 scalpel blade.  the blunt-tipped hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmhg.  the epigastric and right subcostal trocars were placed under direct vision.  the right upper quadrant was well visualized.  the gallbladder was noted to be significantly distended with surrounding dense adhesions.  the fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose bovie dissector and the blunt kittner peanut dissector.  further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  the cystic duct was clipped x3 and then divided.  the cystic artery was dissected out in like fashion, clipped x3, and then divided.  the gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip bovie cautery with good hemostasis.  prior to removal of the gallbladder, all irrigation fluid was clear.  no active bleeding or oozing was seen.  all clips were noted to be secured and intact and in place.  the gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  the gallbladder was retrieved through the umbilical fascial defect and submitted to pathology.  the camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  the insufflation was allowed to escape.  the umbilical fascia was closed using interrupted #1 vicryl sutures.  finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 monocryl.  sterile dressings were applied.  the patient tolerated the procedure well.,",37
"subjective:,  this is a 12-year-old male who comes in for healthy checkups and sports physical.  no major concerns today.  he is little bit congested at times.  he has been told he is allergic to grasses.  they have done over-the-counter claritin and that seems to help but he is always sniffling mother reports.  he has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,past medical history:,  otherwise, reviewed.  very healthy.,current medications:,  claritin p.r.n.,allergies to medicines:,  none.,family social history:,  everyone else is healthy at home currently.,dietary:,  he is on whole milk and does a variety of foods.  growth chart is reviewed with mother.  voids and stools well.,developmental:,  he is in seventh grade and going out for cross-country and track.  he is supposed to be wearing glasses, is not today.  we did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  his hearing was normal today and no concerns with speech.,physical examination:,general:  a well-developed, well-nourished male in no acute distress.,dermatologic:  without rash or lesion.,heent:  head normocephalic and atraumatic.  eyes:  pupils equal, round and reactive to light.  extraocular movements intact.  red reflexes are present bilaterally.  optic discs are sharp with normal vasculature.  ears:  tympanic membranes are gray, translucent with normal light reflex.  nares are very congested.  turbinates swollen and boggy.,neck:  supple without masses.,chest:  clear to auscultation and percussion, easy respirations.  no accessory muscle use.,cardiovascular:  regular rate and rhythm without murmurs, rubs, heaves or gallops.,back:  symmetric with no scoliosis or kyphosis noted.  normal flexibility.  femoral pulses 2+ and symmetric.,abdomen:  soft, nontender, nondistended without hepatosplenomegaly.,gu exam:  normal tanner iii male.  testes descended bilaterally.  no abnormal rash, discharge, or scars.,extremities:  pink and warm.  moves all extremities well with normal function and strength in the arms and legs.  normal balance, station, and gait.  normal speech.,neurologic:  nonfocal with normal speech, station, gait, and balance.,assessment:,  healthy tanner iii male, developing normally.,plan:,1.  diet, growth, safety, drugs, violence, and social competence all discussed.,2.  immunizations reviewed.,3.  we will place him on clarinex 5 mg once daily, some rhinocort-aq nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",28
"preoperative diagnosis:,  acute appendicitis.,postoperative diagnoses:,1.  pelvic inflammatory disease.,2.  periappendicitis.,procedure performed:,1.  laparoscopic appendectomy.,2.  peritoneal toilet and photos.,anesthesia:  ,general.,complications: , none.,estimated blood loss:,  less than 10 cc.,indications for procedure: , the patient is a 31-year-old african-american female who presented with right lower quadrant abdominal pain presented with acute appendicitis.  she also had mild leukocytosis with bright blood cell count of 12,000.  the necessity for diagnostic laparoscopy was explained and possible appendectomy.  the patient is agreeable to proceed and signed preoperatively informed consent.,procedure: , the patient was taken to the operative suite and placed in the supine position under general anesthesia by anesthesia department.,the preoperative foley, antibiotics, and ng tube are placed for decompression and the anterior abdominal wall was prepped and draped in the usual sterile fashion and infraumbilical incision is performed with a #10 blade scalpel with anterior and superior traction on the abdominal wall.  a veress needle was introduced and 15 mm pneumoperitoneum is created with co2 insufflation.  at this point, the veress needle was removed and a 10 mm trocar is introduced intraperitoneally.  a second 5 mm port was introduced in the right upper quadrant under direct visualization and blunted graspers were introduced to bring the appendix into view.  with the aid of a laparoscope, the pelvis was visualized.  the ovaries are brought in views and photos are taken.  there is evidence of a purulence in the cul-de-sac and ________ with a right ovarian hemorrhagic cyst.  attention was then turned on the right lower quadrant.  the retrocecal appendix is freed with peritoneal adhesions removed with endoshears.  attention was turned to the suprapubic area.  the 12 mm port was introduced under direct visualization and the mesoappendix was identified.  a 45 mm endovascular stapling device was fired across the mesoappendix and the base of the appendix sequentially with no evidence of bleeding or leakage from the staple line.  next, ________ tube was used to obtain gram stain and cultures of the pelvic fluid and a pelvic toilet was performed with copious irrigation of sterile saline.  next, attention was turned to the right upper quadrant.  there is evidence of adhesions from the liver surface to the anterior abdominal wall consistent with fitz-hugh-curtis syndrome also a prior pelvic inflammatory disease.  all free fluid is aspirated and patient's all port sites are removed under direct visualization and the appendix is submitted to pathology for final pathology.  once the ports are removed the pneumoperitoneum is allowed to escape for patient's postoperative comfort and two larger port sites at the suprapubic and infraumbilical sites are closed with #0 vicryl suture on a ur-6 needle.  local anesthetic is infiltrated at l3 port sites for postoperative analgesia and #4-0 vicryl subcuticular closure is performed with undyed vicryl.  steri-strips are applied along with sterile dressings.  the patient was awakened from anesthesia without difficulty and transferred to recovery room with postoperative broad-spectrum iv antibiotics in the general medical floor.  routine postoperative care will be continued on this patient.",37
"exam:,mri of the right ankle,clinical:,pain.,findings:,the bone marrow demonstrates normal signal intensity. there is no evidence of bone contusion or fracture. there is no evidence of joint effusion. tendinous structures surrounding the ankle joint are intact. no abnormal mass or fluid collection is seen surrounding the ankle joint.,impression,: normal mri of the right ankle.",30
"chief complaint:,  falls at home.,history of present illness:,  the patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  they noted that she frequently came to the emergency room for ""attention.""  the patient denied any chest pain or pressure and no change to exercise tolerance.  the patient denied any loss of consciousness or incontinence.  she denies any seizure activity.  she states that she ""tripped"" at home.  family states she frequently takes darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  they stated that she has numerous medications at home, but they were not sure if she was taking them.  the patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  the patient denied si or hi.,physical examination:,general:  the patient is pleasant 82-year-old female in no acute distress.,vital signs:  stable.,heent:  negative.,neck:  supple.  carotid upstrokes are 2+.,lungs:  clear.,heart:  normal s1 and s2.  no gallops.  rate is regular.,abdomen:  soft.  positive bowel sounds.  nontender.,extremities:  no edema.  there is some ecchymosis noted to the left great toe.  the area is tender; however, metatarsal is nontender.,neurological:  grossly nonfocal.,hospital course: , a psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  continue paxil and xanax use was recommended.  the patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,discharge diagnoses:,1.  falls ,2.  anxiety and depression.,3.  hypertension.,4.  hypercholesterolemia.,5.  coronary artery disease.,6.  osteoarthritis.,7.  chronic obstructive pulmonary disease.,8.  hypothyroidism.,condition upon discharge: , stable.,discharge medications: , tylenol 650 mg q.6h. p.r.n., xanax 0.5 q.4h. p.r.n., lasix 80 mg daily, isordil 10 mg t.i.d., kcl 20 meq b.i.d., lactulose 10 g daily, cozaar 50 mg daily, synthroid 75 mcg daily, singulair 10 mg daily, lumigan one drop both eyes at bed time, nitroquick p.r.n., pravachol 20 mg daily, feldene 20 mg daily, paxil 20 mg daily, minipress 2 mg daily, provera p.r.n., advair 250/50 one puff b.i.d., senokot one tablet b.i.d., timoptic one drop ou daily, and verapamil 80 mg b.i.d.,allergies: , none.,activity: , per pt.,follow-up: , the patient discharged to a skilled nursing facility for further rehabilitation.",31
"preoperative diagnosis: , malignant pleural effusion, left, with dyspnea.,postoperative diagnosis: , malignant pleural effusion, left, with dyspnea.,procedure:  ,thoracentesis, left.,description of procedure: , the patient was brought to the recovery area of the operating room.  after obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  initially, i tried to use the thoracentesis set after 1% xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  therefore, i had to use a #18 spinal needle, which i had to use almost in its entire length to reach the fluid.  from then on, i proceeded manually to withdraw 2000 ml of a light milky fluid.,the patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  at that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  at any rate, we gave her bolus of 250 ml of normal saline and the patient returned to her room for additional hours of observation.  we then thought that if she was doing fine, then we will send her home.,a chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,",37
"procedures: , left heart catheterization, left ventriculography, and left and right coronary arteriography.,indications: , chest pain and non-q-wave mi with elevation of troponin i only.,technique:  ,the patient was brought to the procedure room in satisfactory condition.  the right groin was prepped and draped in routine fashion.  an arterial sheath was inserted into the right femoral artery.,left and right coronary arteries were studied with a 6fl4 and 6fr4 judkins catheters respectively.  cine coronary angiograms were done in multiple views.,left heart catheterization was done using the 6-french pigtail catheter.  appropriate pressures were obtained before and after the left ventriculogram, which was done in the rao view.,at the end of the procedure, the femoral catheter was removed and angio-seal was applied without any complications.,findings:,1.  lv is normal in size and shape with good contractility, ef of 60%.,2.  lmca normal.,3.  lad has 20% to 30% stenosis at the origin.,4.  lcx is normal.,5.  rca is dominant and normal.,recommendations: , medical management, diet, and exercise.  aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  follow up in the clinic.",3
"exam:,  renal ultrasound.,history: , renal failure, neurogenic bladder, status-post cystectomy.,technique: , multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes.,comparison:,  most recently obtained mm/dd/yy.,findings:,  the right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  the imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  there is no evidence of cortical thinning.,incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow.,impression:,1.  no evidence of hydronephrosis.,2.  mass within the right lobe of the liver.  the patient apparently has a severe iodine allergy.  further evaluation with mri is recommended.,3.  the results of this examination were given to xxx in dr. xxx office on mm/dd/yy at xxx,",20
"subjective:,  overall, she has been doing well.  her blood sugars have usually been less than or equal to 135 by home glucose monitoring.  her fasting blood sugar today is 120 by our accu-chek.  she is exercising three times per week.  review of systems is otherwise unremarkable. ,objective:,  her blood pressure is 110/60.  other vitals are stable.  heent:  unremarkable.  neck:  unremarkable.  lungs:  clear.  heart:  regular.  abdomen:  unchanged.  extremities:  unchanged.  neurologic:  unchanged. ,assessment:,  ,1.  niddm with improved control. ,2.  hypertension. ,3.  coronary artery disease status post coronary artery bypass graft. ,4.  degenerative arthritis. ,5.  hyperlipidemia. ,6.  hyperuricemia. ,7.  renal azotemia. ,8.  anemia. ,9.  fibroglandular breasts. ,plan:,  we will get follow-up labs today.  we will continue with current medications and treatment.  we will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately month dd, yyyy.  the patient is advised to proceed with previous recommendations.  she is to follow-up with ophthalmology and podiatry for diabetic evaluation and to return for follow-up as directed.",34
"reason for exam: , pregnant female with nausea, vomiting, and diarrhea.,findings: , the uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  a yolk sac is visualized.  what appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,please note however that no fetal heart tones are seen.  however, fetal heart tones would be expected at this age.,the right ovary measures 3.1 x 1.6 x 2.3 cm.  the left ovary measures 3.3 x 1.9 x 3.5 cm.  no free fluid is detected.,impression: , single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  a live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  a close interval followup in correlation with beta-hcg is necessary as findings may represent an inevitable abortion.",32
"preoperative diagnosis:,  left carpal tunnel syndrome.,postoperative diagnosis:,  left carpal tunnel syndrome.,operations performed:,  endoscopic carpal tunnel release.,anesthesia:,  i.v. sedation and local (1% lidocaine).,estimated blood loss:,  zero.,complications:,  none.,procedure in detail: , with the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  the arm was exsanguinated.  the tourniquet was elevated at 290 mm/hg.  construction lines were made on the left palm to identify the ring ray.  a transverse incision was made in the wrist, between fcr and fcu, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  blunt dissection exposed the antebrachial fascia.  hemostasis was obtained with bipolar cautery.  a distal-based window in the antebrachial fascia was then fashioned.  care was taken to protect the underlying contents.  a proximal forearm fasciotomy was performed under direct vision.  a synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  hamate sounds were then used to palpate the hook of hamate.  the endoscopic instrument was then inserted into the proximal incision.  the transverse carpal ligament was easily visualized through the portal.  using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,the distal end of the transverse carpal ligament was then identified in the window.  the blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  after complete division o the transverse carpal ligament, the instrument was reinserted.  radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,the wound was then closed with running subcuticular stitch.  steri-strips were applied, and sterile dressing was applied over the steri-strips.  the tourniquet was deflated.  the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition, having tolerated the procedure well.",37
"indications:,  chest pain.,procedure done:,  graded exercise treadmill stress test.,stress ecg results:,  the patient was stressed by continuous graded treadmill testing for nine minutes of the standard bruce protocol.  the heart rate increased from 68 beats per minute to 178 beats per minute, which is 100% of the maximum predicted target heart rate.  the blood pressure increased from 120/70 to 130/80.  the baseline resting electrocardiogram reveals a regular sinus rhythm.  the tracing is within normal limits.  symptoms of chest pain occurred with exercise.  the pain persisted during the recovery process and was aggravated by deep inspiration.  marked chest wall tenderness noted.  there were no ischemic st segment changes seen during exercise or during the recovery process.,conclusions,:,1.  stress test is negative for ischemia.,2.  chest wall tenderness occurred with exercise.,3.  blood pressure response to exercise is normal.",3
"preoperative diagnosis: , retained hardware in left elbow.,postoperative diagnosis:,  retained hardware in left elbow.,procedure: , hardware removal in the left elbow.,anesthesia: , procedure done under general anesthesia.  the patient also received 4 ml of 0.25% marcaine of local anesthetic.,tourniquet:  ,there is no tourniquet time.,estimated blood loss:  ,minimal.,complications:  ,no intraoperative complications.,history and physical:  ,the patient is a 5-year, 8-month-old male who presented to me direct from ed with distracted left lateral condyle fracture.  he underwent screw compression for the fracture in october 2007.  the fracture has subsequently healed and the patient presents for hardware removal.  the risks and benefits of surgery were discussed.  the risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  all questions were answered and the family agreed to the above plan.,procedure: , the patient was taken to the operating room, placed supine on the operating table.  general anesthesia was then administered.  the patient's left upper extremity was then prepped and draped in standard surgical fashion.  using his previous incision, dissection was carried down through the screw.  a guide wire was placed inside the screw and the screw was removed without incident.  the patient had an extension lag of about 15 to 20 degrees.  elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  the washer was also removed without incident.  wound was then irrigated and closed using #2-0 vicryl and #4-0 monocryl.  wound was injected with 0.25% marcaine.  the wound was then dressed with steri-strips, xeroform, 4 x4 and bias.  the patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,discharge note: , the patient will be discharged on date of surgery.  he is to follow up in one week's time for a wound check.  this can be done at his primary care physician's office.  the patient should keep his postop dressing for about 4 to 5 days.  he may then wet the wound, but not scrub it.  the patient may resume regular activities in about 2 weeks.  the patient was given tylenol with codeine 10 ml p.o. every 3 to 4 hours p.r.n.",37
"reason for consultation: , atrial fibrillation and shortness of breath.,history of presenting illness: , the patient is an 81-year-old gentleman.  the patient had shortness of breath over the last few days, progressively worse.  yesterday he had one episode and got concerned and came to the emergency room, also orthopnea and paroxysmal dyspnea.  coronary artery disease workup many years ago.  he also has shortness of breath, weakness, and tiredness.,coronary risk factors: , history of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,family history: , positive for coronary artery disease.,surgical history: , knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,medications: , thyroid supplementation, atenolol 25 mg daily, lasix, potassium supplementation, lovastatin 40 mg daily, and coumadin adjusted dose.,allergies: , aspirin.,personal history:,  married, ex-smoker, and does not consume alcohol.  no history of recreational drug use.,past medical history: , hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,surgical history: , as above.,presentation history: , shortness of breath, weakness, fatigue, and tiredness.  the patient also relates history of questionable tia in 1994.,review of systems:,constitutional:  weakness, fatigue, tiredness.,heent:  no history of cataracts, blurry vision or glaucoma.,cardiovascular:  arrhythmia, congestive heart failure, no coronary artery disease.,respiratory:  shortness of breath.  no pneumonia or valley fever.,gastrointestinal:  nausea, no vomiting, hematemesis, or melena.,urological:  some frequency, urgency, no hematuria.,musculoskeletal:  arthritis, muscle weakness.,skin:  chronic skin changes.,cns:  history of tia.  no cva, no seizure disorder.,endocrine:  nonsignificant.,hematological:  nonsignificant.,psychological:  no anxiety or depression.,physical examination:,vital signs:  pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,heent:  atraumatic and normocephalic.,neck:  neck veins flat.  no significant carotid bruits.,lungs:  air entry bilaterally fair, decreased in basal areas.  no rales or wheezes.,heart:  pmi displaced.  s1 and s2 regular.,abdomen:  soft and nontender.  bowel sounds present.,extremities:  chronic skin changes.  pulses are palpable.  no clubbing or cyanosis.,cns:  grossly intact.,laboratory data: , h&h stable 30 and 39, inr of 1.86, bun and creatinine within normal limits, potassium normal limits.  first set of cardiac enzymes profile negative.  bnp 4810.,chest x-ray confirms unremarkable findings.  ekg reveals atrial fibrillation, nonspecific st-t changes.,impression:",3
"exam:,mri right foot,clinical:,pain and swelling in the right foot.,findings: ,obtained for second opinion interpretation is an mri examination performed on 11-04-05.,there is a transverse fracture of the anterior superior calcaneal process of the calcaneus. the fracture is corticated however and there is an active marrow stress phenomenon. there is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,there is no substantial joint effusion of the calcaneocuboid articulation. there is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,normal plantar calcaneonavicular spring ligament.,normal talonavicular articulation.,there is minimal synovial fluid within the peroneal tendon sheaths.,axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. the peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. the peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,there is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of henry.,there is edema extending along the deep surface of the extensor digitorum brevis muscle.,normal anterior, subtalar and deltoid ligamentous complex.,normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,the lisfranc’s ligament is intact.,the achilles tendon insertion has been excluded from the field-of-view.,normal plantar fascia and intrinsic plantar muscles of the foot.,there is mild venous distention of the veins of the foot within the tarsal tunnel.,there is minimal edema of the sinus tarsus. the lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,normal deltoid ligamentous complex.,normal talar dome and no occult osteochondral talar dome defect.,impression:,transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,small ganglion intwined within the bifurcate ligament.,interstitial edema of the short plantar calcaneocuboid ligament.,minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of henry.,minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.",30
"preoperative diagnosis: , status post mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,postoperative diagnosis: , status post mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,procedures:,1.  repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2.  repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,assistant: , none.,anesthesia: , attended local by strickland and associates.,complications: , none.,description of procedure: , the patient was taken to the operating room, placed in supine position.  dressing was removed from the left eye, which revealed the defect as noted above.  after systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid.  the patient was prepped and draped in the usual ophthalmic fashion.  protective scleral shell was placed in the left eye.  a 4-0 silk traction sutures placed through the upper eyelid margin.  the medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound.  the eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid.  relaxing incisions were made both medially and laterally and mueller's muscle was subsequently dissected free from the superior tarsal border.  the tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 vicryl sutures and one 4-0 vicryl suture.  the protective scleral shell was removed from the eye.  the medial aspect of the eyelid was advanced temporally.  the tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 vicryl sutures.  the conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 vicryl suture.  the upper eyelid wound was present.  it was advanced to the advanced tarsoconjunctival pedicle temporally.  the conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 vicryl sutures.  skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 vicryl sutures.  burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 vicryl suture.  temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 vicryl suture to the periosteum overlying the lateral orbital rim.  the skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 vicryl followed by wound closure temporally with interrupted 7-0 vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure.  erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure.  the patient tolerated the procedure well and left the operating room in excellent condition.  there were no apparent complications.",25
"exam: , ct of the abdomen and pelvis without contrast.,history: , lower abdominal pain.,findings:,  limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  there is a 1.6 cm nodular density at the left posterior sulcus.,noncontrast technique limits evaluation of the solid abdominal organs.  cardiomegaly and atherosclerotic calcifications are seen.,hepatomegaly is observed.  there is calcification within the right lobe of the liver likely related to granulomatous changes.  subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  there is splenomegaly seen.  there are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  the pancreas appears atrophic.  there is a left renal nodule seen, which measures 1.9 cm with a hounsfield unit density of approximately 29, which is indeterminate.,there is mild bilateral perinephric stranding.  there is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  there is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  bilateral ureters appear normal in caliber along their visualized course.  the bladder is partially distended with urine, but otherwise unremarkable.,postsurgical changes of hysterectomy are noted.  there are pelvic phlebolith seen.  there is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,scattered colonic diverticula are observed.  the appendix is within normal limits.  the small bowel is unremarkable.  there is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  the hernia neck measures approximately 2.7 cm.  there is stranding of the fat within the hernia sac.,there are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  degenerative changes of the spine are observed.,impression:,1.  anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  nodule in the left lower lobe, recommend follow up in 3 months.,3.  indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol ct or mri.,4.  hepatomegaly with changes suggestive of cirrhosis.  there is also splenomegaly observed.,5.  low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.",14
"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.",5
"exam: , digital screening mammogram.,history:,  51-year-old female presents for screening mammography.  patient denies personal history of breast cancer.  breast cancer was reported in her maternal aunt.,technique:,  craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  comparison is made with the previous performed on mm/dd/yy. icad second look proprietary software was utilized.,findings:  ,the breasts demonstrate a mixture of adipose and fibroglandular elements.  composition appears similar.  multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  no dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  skin overlying both breasts is unremarkable.,impression: , stable and benign mammographic findings.  continued yearly mammographic screening is recommended.,birads classification 2 - benign,mammography information:,1.  a certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  these images were obtained with fda-approved digital mammography equipment, and icad secondlook software version 7.2 was utilized.",23
"delivery note: , the patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated.  membranes ruptured this morning by me with some meconium.  an iupc was placed.  some pitocin was started because the contractions were very weak.  she progressed in labor throughout the day.  finally getting the complete at around 1530 hours and began pushing.  pushed for about an hour and a half when she was starting to crown.  the foley was already removed at some point during the pushing.  the epidural was turned down by the anesthesiologist because she was totally numb.  she pushed well and brought the head drown crowning, at which time i arrived and setting her up delivery with prepping and draping.  she pushed well delivering the head and delee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed.  with delivery of the head, i could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to rt in attendance.  exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although i cannot see good fascia around the sphincter anteriorly.  the placenta separated with some bleeding seen and was assisted expressed and completely intact.  uterus firmed up well with iv pit.  repair of the tear with 2-0 vicryl stitches and a 3-0 vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural.  once this was complete, mom and baby doing well.  baby was a female infant.  apgars 8 and 9.",23
"preoperative diagnoses:,1.  36th and 4/7th week, intrauterine growth rate.,2.  charcot-marie-tooth disease.,3.  previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  previous spinal fusion.,5.  two previous c-sections.  the patient refuses trial labor.  the patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,postoperative diagnoses:,1.  36th and 4/7th week, intrauterine growth rate.,2.  charcot-marie-tooth disease.,3.  previous amniocentesis showing positive fetal lung maturity, family planning complete.,4.  previous spinal effusion.,5.  two previous c-section.  the patient refuses trial labor.  the patient is with regular contractions dilated to 3, possibly an early labor, contractions are getting more and more painful.,6.  adhesions of bladder.,7.  poor fascia quality.,8.  delivery of a viable female neonate.,procedure performed:,1.  a repeat low transverse cervical cesarean section.,2.  lysis of adhesions.,3.  dissection of the bladder of the anterior abdominal wall and away from the fascia.,4.  the patient also underwent a bilateral tubal occlusion via hulka clips.,complications: , none.,blood loss:,  600 cc.,history and indications:  ,indigo carmine dye bladder test in which the bladder was filled, showed that there was no defects in the bladder of the uterus.  the uterus appeared to be intact.  this patient is a 26-year-old caucasian female.  the patient is well known to the ob/gyn clinic.  the patient had two previous c-sections.  she appears to be in probably early labor.  she had an amniocentesis early today.  she is contracting regularly about every three minutes.  the contractions are painful and getting much more so since the amniocentesis.  the patient had fetal lung maturity noted.  the patient also has probable iugr as none of her babies have been over 4 lb.  the patient's baby appears to be somewhat small.  the patient suffers from charcot-marie-tooth disease, which has left her wheelchair bound.  the patient has had a spinal fusion, however, family planning is definitely complete per the patient.  the patient refuses trial labor.  the patient and i discussed the consent.  she understands the foreseeable risks and complications, alternative treatment of the procedure itself, and recovery.  her questions were answered.  the patient also understands that when we occlude her tube that she is at risk for failure of this part of the procedure, which would result in either an intrauterine or ectopic pregnancy.  the patient understands this and would like to try our best.,procedure:  ,the patient was taken back to the operative suite.  she was given general anesthetic by department of anesthesiology.  once again, in layman's terms, the patient understands the risks.  the patient had the informed consent reviewed and understood.  the patient has had a pfannenstiel incision, which was slightly bent towards the right side favoring the right side.  the patient had the first knife went through this incision.  the second knife was used to go to the level of fascia.  the fascia was very thin, ruddy in appearance, and with abundant scar tissue.  the fascia was incised.  following this, we were able to see the peritoneum.  there was really no obvious rectus abdominal muscles noted.  they were very weak, atrophic, and thin.  the patient has the peritoneum tented up.  we entered the abdominal cavity.  the bladder flap was then entered into the anterior abdominal wall and to the underlying area of the fascia.  the bladder flap was then entered into the uterus as well.  there are some bladder adhesions.  we removed these adhesions and we removed the bladder of the fascia.  we dissected the bladder of the lower segment.  we made a small nick on the lower segment.  we were able to utilize the blunt end of the knife to enter into the uterine cavity.  the baby was in occiput transverse position with the ear being cocked at such a position as well.  the patient's baby was delivered without difficulty.  it was a 4 lb and 10 oz baby girl who vigorously cried well.  there was a prolapse of the umbilical cord just below the chin as well and this may be attributed to the decelerations we caught on the monitor strip right before we decided to have her undergo resection.  the patient's placenta was delivered.  there was no retained placenta.  the uterine incision was closed with two layers of #0 vicryl, the second layer imbricating over the first.  the patient on the right side had the inferior epigastric artery and the vein just underneath the peritoneum easily visualized.  then we ligated this as there was bleeding and oozing.  the patient had the indigo carmine instilled into the bladder with some saline about 300 cc.  the 400 cc was instilled.  the bladder appears to be intact.  the bladder did require extensive dissection of the fascia in order to be able to get a proper fascial edges for closure and dissection of the lower uterine segment.  there was some oozing around the area of the bladder.  we placed an avitene there.  the two hulka clips were placed perpendicular to going across each fallopian tube into the mesosalpinx.  the patient has two clips on each side.  there was excellent tubal occlusion and placement.  the uterus was placed back into the abdominal cavity.  we rechecked again.  the tubal placement was excellent.  it did not involve the round ligaments, uterosacral ligaments, the uteroovarian ligaments, and the tube into the mesosalpinx.  the patient then underwent further examination.  hemostasis appeared to be good.  the fascia was reapproximated with short running intervals of #0 vicryl across the fascia.  we took care not to get into any bleeders and to make sure that the fascia was indeed closed as best as it was possible.  the scarpa's fascia was reapproximated with #0 gut.  the skin was reapproximated then as well via subcutaneous closure.  the patient's sponge and needle counts found to be correct.  uterus appeared to be normal prior to closure.  bladder appeared to be normal.  the patient's blood loss is 600 cc.",37
"procedure: , circumcision.,signed informed consent was obtained and the procedure explained.,the child was placed in a circumstraint board and restrained in the usual fashion.  the area of the penis and scrotum were prepared with povidone iodine solution.  the area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  a dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  a dorsal slit was made, and the prepuce was dissected away from the glans penis.  a ** gomco clamp was properly placed for 5 minutes.  during this time, the foreskin was sharply excised using a #10 blade.  with removal of the clamp, there was a good cosmetic outcome and no bleeding.  the child appeared to tolerate the procedure well.  care instructions were given to the parents.",37
"chief complaint:, left foot pain.,history:, xyz is a basketball player for university of houston who sustained an injury the day prior. they were traveling. he came down on another player's foot sustaining what he describes as an inversion injury. swelling and pain onset immediately. he was taped but was able to continue playing he was examined by john houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. he has been in a walking boot. he has been taped firmly. pain with weightbearing activities. he is limping a bit. no significant foot injuries in the past. most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,physical exam:, he does have some swelling from the hindfoot out toward the midfoot. his arch is maintained. his motion at the ankle and subtalar joints is preserved. forefoot motion is intact. he has pain with adduction and abduction across the hindfoot. most of this discomfort is laterally. his motor strength is grossly intact. his sensation is intact, and his pulses are palpable and strong. his ankle is not tender. he has minimal to no tenderness over the atfl. he has no medial tenderness along the deltoid or the medial malleolus. his anterior drawer is solid. his external rotation stress is not painful at the ankle. his tarsometatarsal joints, specifically 1, 2 and 3, are nontender. his maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. some tenderness over the dorsolateral side of the talonavicular joint as well. the medial talonavicular joint is not tender.,radiographs:, those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. i don't see a definite fracture. the tarsometarsal joints are anatomically aligned. radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. review of an mr scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. also some changes along the dorsal talonavicular joint. i don't see any significant marrow edema or definitive fracture line. ,impression:,  left chopart joint sprain.,plan:,  i have spoken to xyz about this. continue with ice and boot for weightbearing activities. we will start him on a functional rehab program and progress him back to activities when his symptoms allow. he is clear on the prolonged duration of recovery for these hindfoot type injuries.",4
"preoperative diagnoses:,1.  abnormal uterine bleeding.,2.  status post spontaneous vaginal delivery.,postoperative diagnoses:,1.  abnormal uterine bleeding.,2.  status post spontaneous vaginal delivery.,procedure performed:,1.  dilation and curettage (d&c).,2.  hysteroscopy.,anesthesia: , iv sedation with paracervical block.,estimated blood loss:,  less than 10 cc.,indications:  ,this is a 17-year-old african-american female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  the patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,procedure:,  the patient was consented and seen in the preoperative suite.  she was taken to the operative suite, placed in a dorsal lithotomy position, and placed under iv sedation.  she was prepped and draped in the normal sterile fashion.  her bladder was drained with the red robinson catheter which produced approximately 100 cc of clear yellow urine.  a bimanual exam was done, was performed by dr. x and dr. z.  the uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  the cervix and vagina were grossly normal with no obvious masses or deformities.  a weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,the uterus was sounded to 8 cm.  the cervix was sterilely dilated with hank dilator and then hagar dilator.  at the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  the dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  under direct visualization, the ostia were within normal limits.  the endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  the hyperplastic tissue did not appear to have calcification or other abnormalities.  there was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  the hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  the endometrial sampling was placed on telfa pad and sent to pathology for evaluation.  a rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  there was a normal consistency of the cervix and the normal step-off.  the uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  the cervix was found to be hemostatic.  the patient was taken off the dorsal lithotomy position and recovered from her iv sedation in the recovery room.  the patient will be sent home once stable from anesthesia.  she will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  the patient is sent home on tylenol #3 prescription as she is allergic to motrin.  the patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  the patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.",37
"preoperative diagnoses:,1.  intrauterine pregnancy at 30 and 4/7th weeks.,2.  previous cesarean section x2.,3.  multiparity.,4.  request for permanent sterilization.,postoperative diagnosis:,1.  intrauterine pregnancy at 30 and 4/7th weeks.,2.  previous cesarean section x2.,3.  multiparity.,4.  request for permanent sterilization.,5.  breach presentation in the delivery of a liveborn female neonate.,procedures performed:,1.  repeat low transverse cesarean section.,2.  bilateral tubal ligation (btl).,tubes: , none.,drains: , foley to gravity.,estimated blood loss: , 600 cc.,fluids:,  200 cc of crystalloids.,urine output:,  300 cc of clear urine at the end of the procedure.,findings:,  operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  there were bowel adhesions noted through the anterior abdominal wall.  the uterus was noted to be within normal limits.  the tubes and ovaries bilaterally were noted to be within normal limits.  the baby was delivered from the right sacral anterior position without any difficulty.  apgars 8 and 9.  weight was 7.5 lb.,indications for this procedure:  ,the patient is a 23-year-old g3 p 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  she had her first c-section because of congenial hip problems.  in her second c-section, baby was breached, therefore, she is scheduled for a third c-section.  the patient also requests sterilization.  therefore, she requested a tubal ligation.,procedure: , after informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with astramorph anesthesia was obtained without any difficulty.  she was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  a pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  the fascia was excised in the midline extended laterally with the mayo scissors.  the superior aspect of the fascial incision was then tented up with ochsner clamps and the underlying rectus muscle dissected off sharply with the metzenbaum scissors.  there was noted dense adhesions at this point as well as a wire mesh was noted.  the anterior aspect of the fascial incision was then tented up with ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  the rectus muscle superiorly was opened with a hemostat.  the peritoneum was identified and entered bluntly digitally.  the peritoneal incision was then extended superiorly up to the level of the mesh.  then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  the bladder blade was inserted and vesicouterine peritoneum was identified and tented up with allis clamps and bladder flap was created sharply with the metzenbaum scissors digitally.  the bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the bandage scissors.  the amniotic fluid was noted to be clear.  at this point, upon examining the intrauterine contents, the baby was noted to be breached.  the right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  the cord was clamped and the baby was then handed off to awaiting pediatricians.  the placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  the uterus was exteriorized and cleared of all clots and debris.  then, the uterine incision was then closed with #0 vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  attention at this time was turned to the tubes bilaterally.,both tubes were isolated and followed all the way to the fimbriated end and tented up with the babcock clamp.  the hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the metzenbaum scissors.  the ends was then burned with the cautery and then using a #2-0 vicryl suture tied down.  both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  the uterus was then replaced back into the abdomen.  the gutters were cleared of all clots and debris.  the uterine incision was then once again inspected and noted to be hemostatic.  the bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  the peritoneum was then closed with #3-0 vicryl in a running fashion.  then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 vicryl in a simple stitch fashion.  the fascia was then closed with #0 vicryl in a running fashion.  the subcutaneous layer and scarpa's fascia were repaired with a #3-0 vicryl.  then, the skin edges were reapproximated using sterile clips.  the dressing was placed.  the uterus was then cleared of all clots and debris manually.  then, the patient tolerated the procedure well.  sponge, lap, and needle, counts were correct x2.  the patient was taken to recovery in sable condition.  she will be followed up throughout her hospital stay.",37
"cervical facet joint injection with contrast.,preprocedure preparation:,  after being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. the patient was placed in the prone position and standard asa monitors applied.  intravenous access was established and iv sedation was used.  for further details of iv sedation and infusion, please refer to anesthesia notes.  fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints.  the skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,procedure details:,  the patient was laid supine.  appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head.  the neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the c4-5 facet joint under fluoroscopic control.  positioning was checked and 0.2 ml of dye was injected.  acceptable dye pattern was seen.  subsequent 1 ml of a mixture of 0.5 ml of 1% lidocaine and 0.5 ml of celestone was injected after aspiration and the patient was monitored.  needle was removed and same procedure carried out on the other side.  postprocedure, no complications were noted.",27
"procedure:  ,laparoscopic tubal sterilization, tubal coagulation.,preoperative diagnosis: , request tubal coagulation.,postoperative diagnosis: , request tubal coagulation.,procedure:  ,under general anesthesia, the patient was prepped and draped in the usual manner.  manipulating probe placed on the cervix, changed gloves.  small cervical stab incision was made, veress needle was inserted without problem.  a 3 l of carbon dioxide was insufflated.  the incision was enlarged.  a 5-mm trocar placed through the incision without problem.  laparoscope placed through the trocar.  pelvic contents visualized.  a 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  under direct vision, the trocar was placed in the abdominal cavity.  uterus, tubes, and ovaries were all normal.  there were no pelvic adhesions, no evidence of endometriosis.  uterus was anteverted and the right adnexa was placed on a stretch.  the tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  the tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  the structure was confirmed to be tube by looking at fimbriated end.  the left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  tube was confirmed by fimbriated end.  gas was lend out of the abdomen.  both punctures repaired with 4-0 vicryl and punctures were injected with 0.5% marcaine 10 ml.  the patient went to the recovery room in good condition.",37
"physical examination,general: , the patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  no dysarthria is noted.  no discomfort on presentation is noted.  ,head: , atraumatic, normocephalic. pupils are equal, round and reactive to light.  extraocular muscles are intact.  sclerae are white without injection or icterus.  fundi are without papilledema, hemorrhages or exudates with normal vessels.  ,ears: , the ear canals are patent without edema, exudate or drainage.  tympanic membranes are intact with a normal cone of light.  no bulging or erythema to indicate infection is present.  there is no hemotympanum.  hearing is grossly intact.  ,nose:,  without deformity, bleeding or discharge.  no septal hematoma is noted.  ,oral cavity:,  no swelling or abnormality to the lip or teeth.  oral mucosa is pink and moist.  no swelling to the palate or pharynx.  uvula is midline.  the pharynx is without exudate or erythema.  no edema is seen of the tonsils.  the airway is completely patent.  the voice is normal.  no stridor is heard.  ,neck: , no signs of meningismus.  no brudzinski or kernig sign is present.  no adenopathy is noted.  no jvd is seen.  no bruits are auscultated.  trachea is midline.  ,chest: , symmetrical with equal breath sounds.  equal excursion.  no hyperresonance or dullness to percussion is noted.  there is no tenderness on palpation of the chest.  ,lungs:  ,clear to auscultation bilaterally.  no rales, rhonchi or wheezes are appreciated.  good air movement is auscultated in all 4 lung fields.  ,heart:,  regular rate and rhythm.  no murmur.  no s3, s4 or rub is auscultated.  point of maximal impulse is strong and in normal position.  abdominal aorta is not palpable.  the carotid upstroke is normal.  ,abdomen:  ,soft, nontender and nondistended.  normal bowel sounds are auscultated.  no organomegaly is appreciated.  no masses are palpated.  no tympany is noted on percussion.  no guarding, rigidity or rebound tenderness is seen on exam.  murphy and mcburney sign is negative.  there is no rovsing, obturator or psoas sign present.  no hepatosplenomegaly and no hernias are noted.  ,rectal:,  normal tone.  no masses.  soft, brown stool in the vault.  guaiac negative.  ,genitourinary:,  penis is normal without lesion or urethral discharge.  scrotum is without edema.  the testes are descended bilaterally.  no masses are palpated.  there is no tenderness.  ,extremities: , no clubbing, cyanosis or edema.  pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  no deformity or signs of trauma.  all joints are stable without laxity.  there is good range of motion of all joints without tenderness or discomfort.  homan sign is negative.  no atrophy or contractures are noted.  ,skin: , no rashes.  no jaundice.  pink and warm with good turgor.  good color.  no erythema or nodules noted.  no petechia, bulla or ecchymosis.  ,neurologic: , cranial nerves ii through xii are grossly intact.  muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. babinski is downgoing bilaterally.  sensation is intact to light touch and vibration.  gait is normal.  romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  there is no ataxia seen on gait testing.  tone is normal.  no pronator drift is seen.  ,psychiatric:  ,the patient is oriented x4.  mood and affect are appropriate.  memory is intact with good short- and long-term memory recall.  no dysarthria is noted.  remote memory is intact.  judgment and insight appear normal.,",5
"1.  the left ventricular cavity size and wall thickness appear normal.  the wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  there is near-cavity obliteration seen.  there also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  there is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by doppler examination.,2.  the left atrium appears mildly dilated.,3.  the right atrium and right ventricle appear normal.,4.  the aortic root appears normal.,5.  the aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  there is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  the tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  estimated pulmonary artery systolic pressure is 49 mmhg.  estimated right atrial pressure of 10 mmhg.,8.  the pulmonary valve appears normal with trace pulmonary insufficiency.,9.  there is no pericardial effusion or intracardiac mass seen.,10.  there is a color doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  the study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,",3
"chief complaint: , right distal ureteral calculus.,history of present illness:  ,the patient had hematuria and a ct urogram at abc radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  he had a kub also showing a teardrop shaped calcification apparently in the right lower ureter.  he comes in now for right ureteroscopy, holmium laser lithotripsy, right ureteral stent placement.,past medical history:,1.  prostatism.,2.  coronary artery disease.,past surgical history:,1.  right spermatocelectomy.,2.  left total knee replacement in 1987.,3.  right knee in 2005.,medications:,1.  coumadin 3 mg daily.,2.  fosamax.,3.  viagra p.r.n.,allergies: , none.,review of systems:,  cardiopulmonary:  no shortness of breath or chest pain.  gi:  no nausea, vomiting, diarrhea or constipation.  gu:  voids well.  musculoskeletal:  no weakness or strokes.,family history: , noncontributory.,physical examination:,general appearance:  an alert male in no distress.,heent:  grossly normal.,neck:  supple.,lungs:  clear.,heart:  normal sinus rhythm.  no murmur or gallop.,abdomen:  soft.  no masses.,genitalia:  normal penis.  testicles descended bilaterally.,rectal:  examination benign.,extremities:  no edema.,impression: , right distal ureteral calculus.,plan: , right ureteroscopy, ureteral lithotripsy.  risks and complications discussed with the patient.  he signed a true informed consent.  no guarantees or warrantees were given.",38
"reason for visit: , followup circumcision.,history of present illness: , the patient had his circumcision performed on 09/16/2007 here at children's hospital.  the patient had a pretty significant phimosis and his operative course was smooth.  he did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  his mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  he is having no difficulty urinating, and his bowel function remains normal.,physical examination:  ,today, the patient looks healthy and happy.  we examined his circumcision site.  his monocryl sutures are still in place.  the healing is excellent, and there is only a mild amount of residual postoperative swelling.  there was one area where he had some recurrent adhesions at the coronal sulcus, and i gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,impression: , satisfactory course after circumcision for severe phimosis with no perioperative complications.,plan:  ,the patient came in followup for his routine care with dr. x, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  if that does occur, we will be happy to see him back at any time.,",34
"chief complaint:,  detox from heroin.,history of present illness: , this is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  the patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,past medical history: , remarkable for chronic pain.  he has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  he has previously been followed by abc but has not seen him for several years.,review of systems:  ,the patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  denies any headache or visual complaints.  no hallucinations.  no chest pain, shortness of breath, abdominal pain or back pain.  denies any abscesses.,social history: , the patient is a smoker.  admits to heroin use, alcohol abuse as well.  also admits today using cocaine.,family history:,  noncontributory.,medications: , he has previously been on analgesics and pain medications chronically.  apparently, he just recently got out of prison.  he has previously also been on klonopin and lithium.  he was previously on codeine for this pain.,allergies: , none.,physical examination: , vital signs:  the patient is afebrile.  he is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  his respiratory rate is normal at 18.  general:  the patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  heent:  unremarkable.  pupils are actually moderately dilated about 4 to 5 mm, but reactive.  extraoculars are intact.  his oropharynx is clear.  neck:  supple.  his trachea is midline.  lungs:  clear.  he has good breath sounds and no wheezing.  no rales or rhonchi.  good air movement and no cough.  cardiac:  without murmur.  abdomen:  soft and nontender.  he has multiple track marks, multiple tattoos, but no abscesses.  neurologic:  nonfocal.,impression: , medical examination for the patient who will be detoxing from heroin.,assessment and plan:  ,at this time, i think the patient can be followed up at xyz.  i have written a prescription of clonidine and phenergan for symptomatic relief and this has been faxed to the pharmacy.  i do not think he needs any further workup at this time.  he is discharged otherwise in stable condition.",15
"procedure: , trigger finger release.,procedure in detail: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,a longitudinal incision was made over the digit's a1 pulley.  dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  the sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the a1 pulley to just proximal to the proximal digital crease.  meticulous hemostasis was maintained with bipolar electrocautery.,the tendons were identified and atraumatically pulled to ensure that no triggering remained.  the patient then actively moved the digit, and no triggering was noted.,after irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,the wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.",37
"reason for visit:,  the patient presents for a followup for history of erythema nodosum.,history of present illness: , this is a 25-year-old woman who is attending psychology classes.  she was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in netherlands.  at that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum.  part of her workup included a colonoscopy.  the findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum.,the skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis.,prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway.  even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions.  she was seen in our clinic and by dermatology on several occasions.  apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased crp.  in the following visits, no evident abnormality has been detected.  in the first visit, here some mtp discomfort detected.  it was thought that erythema nodosum may be present.  however, the evaluation of dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture.  when she was initially seen here, a suspicion of ibd, sarcoid inflammatory arthropathy, and lupus was raised.  she had an equivocal rheumatoid fracture, but her ccp was negative.  she had an ana, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded dna, rnp, smith, ro, la were negative.  her cardiolipin panel antibodies were negative as well.  we followed the igm, igg, and iga being less than 10.  however, she did have a beta-2 glycoprotein 1 or an rvvt tested and this may be important since she has a livedo pattern.  it was thought that the onset of lupus may be the case.  it was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum.  for the fear of possible lymphoma, she underwent ct of the chest, abdomen, and pelvis.  it was done also in order to rule out sarcoid and the result was unremarkable.  based on some changes in her bowel habits and evidence of b12 deficiency with a high methylmalonic and high homocystine levels along with a low normal b12 in addition to iron studies consistent with iron deficiency and an initially low mcv, the possibility of inflammatory bowel disease was employed.  the patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal.  a second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen.  however, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging crohn disease and i will need to discuss with gastroenterology what is the significance of that.  her possible b12 deficiency and iron deficiency were never addressed during her stay here in the united states.,in the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne.  we decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily.  while this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain.  she was reevaluated by dermatology for that and no evidence of erythema nodosum was felt to be present.  out plan was to proceed with a dexa scan, at some point check a vitamin d level, and order vitamin d and calcium over the counter for bone protection purposes.  however, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease.,her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis.,her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until i took over her care last august.  i have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently.  she also has evidence of acne, which does not seem to be present at the moment.  she also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed.,her workup during the initial appointment included an ace level, which was normal.  she also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110.  her rvvt was normal, her rheumatoid factor was negative.  her ana was 1:40, speckled pattern.  the double-stranded dna was negative.  her rnp and smith were negative as well.  ro and la were negative and cardiolipin antibodies were negative as well.  a urinalysis at the moment was completely normal.  a crp was 2.3 in the initial appointment, which was high.  a ccp was negative.  her cbc had shown microcytosis and hypochromia with a hematocrit of 37.7.  this improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3.,the patient returns here today, as i mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles.  i am mentioning here that photosensitivity rash was mentioned in the past.  she tells me that she had it twice back in europe after skiing where her whole face was swollen.  her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily.  today we discussed about the effect of colchicine on a possible pregnancy.,medications: , prednisone was stopped.  vitamin d and calcium over the counter, we need to verify that.  colchicine 0.6 mg daily which we are going to stop, ranitidine 150 mg as needed, which she does not take frequently.,findings:,  on physical examination, she is very pleasant, alert, and oriented x 3 and not in any acute distress.  there is some evidence of faint subcutaneous lesions in both shins bilaterally, but with mild tenderness, but no evidence of classic erythema nodosum.  stasis dermatitis changes in both lower extremities present.  mild livedo reticularis is present as well.,there is some periarticular ankle edema as well.  laboratory data from 04/23/07, show a normal complete metabolic profile with a creatinine of 0.7, a cbc with a white count of 7880, hematocrit of 40.3, and platelets of 228.  her microcytosis and hypochromia has resolved.  her serum electrophoresis does not show a monoclonal abnormality.  her vitamin d levels were 26, which suggests some mild insufficiency and she would probably benefit by vitamin d supplementation.  this points again towards some ileum pathology.  her anca b and c were negative.  her pf3 and mpo were unremarkable.  her endomysial antibodies were negative.  her sed rate at this time were 19.  the highest has been 30, but prior to her appointment here was even higher.  her ana continues to be positive with a titer of 1:40, speckled pattern.  her double-stranded dna is negative.  her serum immunofixation confirmed the absence of monoclonal abnormality.  her urine immunofixation was not performed.  her igg, iga, and igm levels are normal.  her ige levels are normal as well.  a urinalysis was not performed this time.  her crp is 0.4.  her tissue transglutaminase antibodies are negative.  her asca is normal and anti-ompc was not tested.  gliadin antibodies iga is 12, which is in the borderline to be considered equivocal, but these are nonspecific.  i am reminding here that her homocystine levels have been 15.7, slightly higher, and that her methylmalonic acid was 385, which is obviously abnormal.  her b12 levels were 216, which is rather low possibly indicating a b12 deficiency.  her iron studies showed a ferritin of 15, a saturation of 9%, and an iron of 30.  her tibc was 345 pointing towards an iron deficiency anemia.  i am reminding you that her ace levels in the past were normal and that she has a microcytosis.  her radiologic workup including a thoracic, abdominal, and pelvic ct did not show any suspicious adenopathy, but only small aortocaval and periaortic nodes, the largest being 8 mm in short axis, likely reactive.  her pelvic ultrasound showed normal uterus adnexa.  her bladder was normal as well.  subcentimeter inguinal nodes were found.  there was no large lytic or sclerotic lesion noted.  her recent endoscopy was unremarkable, but the microscopy showed some eosinophil aggregation, which may be pointing towards allergy or an evolving crohn disease.  her capsule endoscopy was limited secondary to rapid transit.  there was only a tiny mucosal red spot in the proximal jejunum without active bleeding, 2 possible erosions were seen in the distal jejunum and proximal ileum.  however, no significant inflammation or bleeding was seen and this could be small bowel crisis.  neither evidence of bleeding or inflammation were seen as well.  specifically, the terminal ileum appeared normal.  recent evaluation by a dermatologist did not verify the presence of erythema nodosum.,assessment:,  this is a 25-year-old woman diagnosed with presumptive erythema nodosum in 2004.  she has been treated with prednisone as in the beginning she had also a wrist and ankle discomfort and high inflammatory markers.  since i took over her care, i have not seen a clear-cut erythema nodosum being present.  no evidence of synovitis was there.  her serologies apart from an ana of 1:40 were negative.  she has a livedo pattern, which has been worrisome.  the issue here was a possibility of inflammatory bowel disease based on deficiency in vitamin b12 as indicated by high methylmalonic and homocystine levels and also iron deficiency.  she also has low vitamin d levels, which point towards terminal ileum pathology as well and she had a history of decreased mcv.  we never received the x-ray of her hands which she had and she never had a dexa scan.  lymphoma has been ruled out and we believe that inflammatory bowel disease, after repeated colonoscopies and the capsule endoscopy, has been ruled out as well.  sarcoid is probably not the case since the patient did not have any lymphadenopathies and her ace levels were normal.  we are going check a ppd to rule out tuberculosis.  we are going to order an rvvt and glycoprotein beta-1 levels in her workup to make sure that an antiphospholipid syndrome is not present given the livedo pattern.  an anti-intrinsic factor will be added as well.  her primary care physician needs to workup the possible b12 and iron deficiency and also the vitamin d deficiency.  in the meanwhile, we feel that the patient should stop taking the colchicine and if she has a flare of her disease then she should present to her dermatologist and have the skin biopsy performed in order to have a clear-cut answer of what is the nature of this skin rash.  regarding her heart murmur, we are going to proceed with an echocardiogram.  a ppd should be placed as well.  in her next appointment, we may fax a requisition for vitamin b replacement.,problems/diagnoses:,  1.  recurrent erythema nodosum with ankle and wrist discomfort, ? arthritis.,2.  iron deficiencies, according to iron studies.,3.  borderline b12 with increased methylmalonic acid and homocystine.,4.  on chronic steroids; vitamin d and calcium is needed; she needs a dexa scan.,5.  typical anca, per records, were not verified here.  anca and asca were negative and the ompc was not ordered.,6.  acne.,7.  recurrent arthralgia not present.  rheumatoid factor, ccp negative, ana 1:40 speckled.,8.  livedo reticularis, beta 2-glycoprotein was not checked, we are going to check it today.  needs vaccination for influenza and pneumonia.,9.  vitamin d deficiency.  she needs replacement with ergocalciferol, but this may point towards ___________ pathology as this was not detected.,10.  recurrent ankle discomfort which necessitates ankle x-rays.,plans:,  we can proceed with part of her workup here in clinic, ppd, echocardiogram, ankle x-rays, and anti-intrinsic factor antibodies.  we can start repleting her vitamin d with __________ weeks of ergocalciferol 50,000 weekly.  we can add an rvvt and glycoprotein to her workup in order to rule out any antiphospholipid syndrome.  she should be taking vitamin d and calcium after the completion of vitamin d replacement.  she should be seen by her primary care physician, have the iron and b12 deficiency worked up.  she should stop the colchicine and if the skin lesion recurs then she should be seen by her dermatologist.  based on the physical examination, we do not suspect that the patient has the presence of any other disease associated with erythema nodosum.  we are going to add an amylase and lipase to evaluate her pancreatic function, rpr, hiv, __________ serologies.  given the evidence of possible malabsorption it may be significant to proceed with an upper endoscopy to rule out whipple disease or celiac disease which can sometimes be associated with erythema nodosum.  an anti-intrinsic factor would be added, as i mentioned.  i doubt whether the patient has behcet disease given the absence of oral or genital ulcers.  she does not give a history of oral contraceptives or medications that could be related to erythema nodosum.  she does not have any evidence of lupus __________ mycosis.  histoplasmosis coccidioidomycosis would be accompanied by other symptoms.  hodgkin disease has probably been ruled out with a cat scan.  however, we are going to add an ldh in future workup.  i need to discuss with her primary care physician regarding the need for workup of her vitamin b12 deficiency and also with her gastroenterologist regarding the need for an upper endoscopy.  the patient will return in 1 month.",8
"xyz, s.,re:  abc,dear dr. xyz,on your kind referral, i had the pleasure of meeting and consulting with abc on mm/dd/yyyy for evaluation regarding extraction of his mandibular left second molar tooth #18.  this previously root-canaled tooth, now failed, is scheduled for removal.  as per your request, i agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,i have given mr. abc an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,we will plan to place two straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  i will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  if you have any additional suggestions or concerns, please give me a call.,best regards,,",7
"procedure performed: , modified radical mastectomy.,anesthesia: , general endotracheal tube.,procedure:  ,after informed consent was obtained, 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 prepped and draped in the usual sterile manner.  care was taken to ensure that the arm was placed in a relaxed manner away from the body to facilitate exposure and to avoid nerve injury.,an elliptical incision was made to incorporate the nipple-areolar complex and the previous biopsy site.  the skin incision was carried down to the subcutaneous fat but no further.  using traction and counter-traction, the upper flap was dissected from the chest wall medially to the sternal border, superiorly to the clavicle, laterally to the anterior border of the latissimus dorsi muscle, and superolaterally to the insertion of the pectoralis major muscle.  the lower flap was dissected in a similar manner down to the insertion of the pectoralis fascia overlying the fifth rib medially and laterally out to the latissimus dorsi.  bovie electrocautery was used for the majority of the dissection and hemostasis tying only the large vessels with 2-0 vicryl.  the breast was dissected from the pectoralis muscle beginning medially and progressing laterally removing the pectoralis fascia entirely.  once the lateral border of the pectoralis major muscle was identified, the pectoralis muscle was retracted medially and the interpectoral fat was removed with the specimen.,the axillary dissection was then begun by incising the fascia overlying axilla proper allowing visualization of the axillary vein.  the highest point of axillary dissection was then marked with a long stitch for identification by the surgical pathologist.  the axilla was then cleared of its contents by sharp dissection.  small vessels entering the axillary vein were clipped and divided.  the axilla was cleared down to the chest wall, and dissection was continued laterally to the subscapular vein.  the long thoracic nerve was cleared identified lying against the chest and was carefully preserved.  the long thoracic nerve represented the posterior most aspect of the dissection.  as the axillary contents were dissected in the posterolateral axilla, the thoracodorsal nerve was identified and carefully preserved.  the dissection continued caudally until the entire specimen was freed and delivered from the operative field.  copious water lavage was used to remove any debris, and hemostasis was obtained with bovie electrocautery.,two jackson-pratt drains were inserted through separate stab incisions below the initial incision and cut to fit.  the most posterior of the 2 was directed into the axilla and the other directed anteriorly across the pectoralis major.  these were secured to the skin using 2-0 silk, which was roman-sandaled around the drain.,the skin incision was approximated with skin staples.  a dressing was applied.  the drains were placed on ""grenade"" suction.  all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",37
"problem:  ,chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,history: , the patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from eugene to portland.  the patient is not a great historian.  most of the history is obtained through the old history and chart that the patient has with her.  according to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  she was initially seen by dr. a back in september 2001 for abdominal pain, nausea and vomiting.  during those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in oregon by dr.  a in august 2001.  it was assumed that this was caused by biliary dyskinesia.  previous to that, an upper endoscopy was performed by dr. b in july 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.",5
"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.",28
"chief complaint / reason for the visit:, patient has been diagnosed to have breast cancer.,breast cancer history:, patient presented with the following complaints: lump in the upper outer quadrant of the right breast that has been present for the last 4 weeks. the lump is painless and the skin over the lump is normal. patient denies any redness, warmth, edema and nipple discharge. patient had a mammogram recently and was told to have a mass measuring 2 cm in the uoq and of the left breast. patient had an excisional biopsy of the mass and subsequently axillary nodal sampling.,pathology:, infiltrating ductal carcinoma, estrogen receptor 56, progesterone receptor 23, s-phase fraction 2., her 2 neu 0 and all nodes negative.,stage:, stage i.,tnm stage:, t1, n0 and m0.,surgery:, s/p lumpectomy left breast and left axillary node sampling. patient is here for further recommendation.,past medical history:, osteoarthritis for 5 years. ashd for 10 years. kidney stones recurrent for 10 years.,screening test history:,  last rectal exam was done on 10/99. last mammogram was done on 12/99. last gynecological exam was done on 10/99. last pap smear was done on 10/99. last chest x-ray was done on 10/99. last f.o.b. was done on 10/99-x3. last sigmoidoscopy was done on 1998. last colonoscopy was done on 1996.,immunization history:, last flu vaccine was given on 1999. last pneumonia vaccine was given on 1996.,family medical history:, father age 85, history of cerebrovascular accident (stroke) and hypertension. mother history of chf and emphysema that died at the age of 78. no brothers and sisters. 1 son healthy at age 54.,past surgical history:, appendectomy. biopsy of the left breast 1996 - benign.",16
"procedures:,1.  esophagogastroduodenoscopy.,2.  colonoscopy with polypectomy.,preoperative diagnoses:,1.  history of esophageal cancer.,2.  history of colonic polyps.,postoperative findings:,1.  intact surgical intervention for a history of esophageal cancer.,2.  melanosis coli.,3.  transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,medications:,  fentanyl 250 mcg and 9 mg of versed.,indications:,  the patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at t2n0m0.,he also has a history of adenomatous polyps and presents for surveillance of this process.,informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,esophagogastroduodenoscopy:,  the patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  the olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,findings:,1.  esophagus:  anatomy consistent with esophagectomy with colonic transposition.,2.  stomach:  revealed colonic transposition with normal mucosa.,3.  duodenum:  normal.,impression: , intact surgical intervention with esophagectomy colonic transposition.,colonoscopy: , the patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  circumferential visualization the colonic mucosa revealed the following:,1.  cecum revealed melanosis coli.,2.  ascending, melanosis coli.,3.  transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  descending, melanosis coli.,5.  sigmoid, melanosis coli.,6.  rectum, melanosis coli.,impression: , diffuse melanosis coli with incidental finding of transverse colon polyps.,recommendation: , follow-up histology.  continue fiber with avoidance of stimulant laxatives.",37
"preoperative diagnoses,1.  herniated disc, c5-c6.,2.  cervical spondylosis, c5-c6.,postoperative diagnoses,1.  herniated disc, c5-c6.,2.  cervical spondylosis, c5-c6.,procedures,1.  anterior cervical discectomy with decompression, c5-c6.,2.  anterior cervical fusion, c5-c6.,3.  anterior cervical instrumentation, c5-c6.,4.  allograft c5-c6.,anesthesia:  ,general endotracheal.,complications:,  none.,patient status: , taken to recovery room in stable condition.,indications: , the patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  we discussed reasonable risks, benefits, and alternatives of various treatment options.  continuation of nonoperative care versus the risks associated with surgery were discussed.  she understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  despite these risks, she felt that current symptoms will be best managed operatively.,summary of surgery in detail: , following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  general anesthetic was administered.  the patient was placed in the supine position.  all prominences and neurovascular structures were well accommodated.  the patient was noted to have pulse in this position.  preoperative x-rays revealed appropriate levels for skin incision.  ten pound inline traction was placed via gardner-wells tongs and shoulder roll was placed.  the patient was then prepped and draped in sterile fashion.  standard oblique incision was made over the c6 vertebral body in the proximal nuchal skin crease.  subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  this was taken down to the prevertebral fascia which was bluntly split.  intraoperative x-ray was taken to ensure proper levels.  longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  inferior spondylosis was removed with high-speed bur.  a scalpel and curette was used to remove the disc.  decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  disc herniation was removed from the right posterolateral aspect of the interspace.  high-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  no further evidence of compression was identified.  hemostasis was achieved with thrombin-soaked gelfoam.  interspace was then distracted with caspar pin distractions set gently.  interspace was then gently retracted with the caspar pin distraction set.  an 8-mm allograft was deemed in appropriate fit.  this was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  the graft was stable to pull-out forces.  distraction and traction was then removed and anterior cervical instrumentation was completed using a depuy trimline anterior cervical plate with 14-mm self-drilling screws.  plate and screws were then locked to the plate.  final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  wounds were copiously irrigated with normal saline.  omohyoid was approximated with 3-0 vicryl.  running 3-0 vicryl was used to close the platysma.  subcuticular monocryl and steri-strips were used to close the skin.  a deep drain was placed prior to wound closure.  the patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  there were no intraoperative complications.  all needle and sponge counts were correct.  intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.",26
"subjective:,  the patient comes in today for a comprehensive evaluation.  she is well-known to me.  i have seen her in the past multiple times.,past medical history/social history/family history: , noted and reviewed today.  they are on the health care flow sheet.  she has significant anxiety which has been under fair control recently.  she has a lot of stress associated with a son that has some challenges.  there is a family history of hypertension and strokes.,current medications:,  currently taking toprol and avalide for hypertension and anxiety as i mentioned.,review of systems:,  significant for occasional tiredness.  this is intermittent and currently not severe.  she is concerned about the possibly of glucose abnormalities such diabetes.  we will check a glucose, lipid profile and a hemoccult test also and a mammogram.  her review of systems is otherwise negative.,physical examination:,vital signs:  as above.,general:  the patient is alert, oriented, in no acute distress.,heent:  perrla.  eomi.  tms clear bilaterally.  nose and throat clear.,neck:  supple without adenopathy or thyromegaly.  carotid pulses palpably normal without bruit.,chest:  no chest wall tenderness.,breast exam:  no asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,heart:  regular rate and rhythm without murmur, clicks, or rubs.,lungs:  clear to auscultation and percussion.,abdomen:  soft, nontender, bowel sounds normoactive.  no masses or organomegaly.,gu:  external genitalia without lesions.  bus normal.  vulva and vagina show just mild atrophy without any lesions.  her cervix and uterus are within normal limits.  ovaries are not really palpable.  no pelvic masses are appreciated.,rectal:  negative.,breasts:  no significant abnormalities.,extremities:  without clubbing, cyanosis, or edema.  pulses within normal limits.,neurologic:  cranial nerves ii-xii intact.  strength, sensation, coordination, and reflexes all within normal limits.,skin:  noted to be normal.  no subcutaneous masses noted.,lymph system:  no lymphadenopathy.,assessment:,  generalized anxiety and hypertension, both under fair control.,plan:,  we will not make any changes in her medications.  i will have her check a lipid profile as mentioned, and i will call her with that.  screening mammogram will be undertaken.  she declined a sigmoidoscopy at this time.  i look forward to seeing her back in a year and as needed.",15
"chief complaint:, neck and lower back pain.,vehicular trauma history:, date of incident: 1/15/2001. the patient was the driver of a small sports utility vehicle and was wearing a seatbelt. the patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. the other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. estimated impact speed was 80 m.p.h. the driver of the other vehicle was reportedly cited by police. the patient was transiently unconscious and came to the scene. there was immediate onset of headaches, neck and lower back pain. the patient was able to exit the vehicle and was subsequently transported by rescue squad to st. thomas memorial hospital, evaluated in the emergency room and released.,neck and lower back pain history:, the patient relates the persistence of pain since the motor vehicle accident. symptoms began immediately following the mva. because of persistent symptoms, the patient subsequently sought chiropractic treatment. neck pain is described as severe. neck pain remains localized and is non-radiating. there are no associated paresthesias. back pain originates in the lumbar region and radiates down both lower extremities. back pain is characterized as worse than the neck pain. there are no associated paresthesias.",26
"past medical history: , significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and pcos.,past surgical history: , none.,social history: , currently employed.  she is married.  she is in sales.  she does not smoke.  she drinks wine a few drinks a month.,current medications: , she is on carafate and prilosec.  she was on metformin, but she stopped it because of her abdominal pains.,allergies: , she is allergic to penicillin.,review of systems:,  negative for heart, lungs, gi, gu, cardiac, or neurologic.  denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,physical examination: , she is afebrile.  vital signs are stable.  heent:  eomi.  perrla.  neck is soft and supple.  lungs clear to auscultation.  she is mildly tender in the abdomen in the right upper quadrant.  no rebound.  abdomen is otherwise soft.  positive bowel sounds.  extremities are nonedematous.  ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,impression/plan: , i have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ercp, and possible need for further surgery among other potential complications.  she understands and we will proceed with the surgery in the near future.,",5
"preoperative diagnosis:,  metopic synostosis with trigonocephaly.,postoperative diagnosis:,  metopic synostosis with trigonocephaly.,procedures:  ,1.  bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  bilateral orbital advancement with (c-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  bilateral forehead reconstruction with autologous graft.,4.  advancement of the temporalis muscle bilaterally.,5.  barrel-stave osteotomies of the parietal bones.,anesthesia: , general.,procedure: , after induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  scalp was clipped.  he was prepped with chloraprep.  incision was infiltrated with 0.5% xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,a bicoronal zigzag incision was made and raney clips used for hemostasis.  subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  these were subgaleal flaps.  bipolar and bovie cautery were used for hemostasis.  the craniectomy was outlined with methylene blue.  the pericranium was incised exposing the bone along the outline of the craniotomy.,paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  one was just above the nasion and the other was near the bregma.  also bilateral pterional bur holes were drilled.  there was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,the dura was separated with a #4 penfield dissector and then the craniotomies were fashioned or cut.  i should say with the midas rex drill using the v5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  great care was taken when removing the bone from the midline.  bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,the wound was irrigated with bacitracin irrigation.,the next step was to perform the orbital osteotomies with careful protection of the orbital contents.  osteotomies were made with the midas rex drill using the v5 bit in the orbital roof bilaterally.  this was a very thick and vertically oriented orbital roof on each side.  midas rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  the osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  bone wax was used for hemostasis.  it was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  so we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  this was done with the midas rex drill using b5 bit.  also, the marked ridge just above the nasion was burred down with the midas rex drill.  the osteotomies were also carried down through the zygoma.  at this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,dr. x cut the bone grafts from the bone flaps and i fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  this created a shelf for the notched bone graft to lean against basically anteriorly.  the posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,the left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for isaac.,at this point the undersurface of the temporalis muscle was scored using the bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 vicryl suture.  this helped fill-in the indentation left by the orbital advancement at the temporal region.,also, i separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,at this point, gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,the wound was then irrigated with bacitracin irrigation.  bleeding had been controlled during the procedure with bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 ml and he received that much in packed cells and he also received a unit of fresh frozen plasma.,at this point, the reconstruction looked good.  the advancement was about 1 cm and we were pleased with the results.  the wound was irrigated and then the gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 vicryl interrupted suture and #5-0 mild chromic on the skin.  the patient tolerated procedure well.  no complications.  sponge and needle counts were correct.  again, blood loss was bout 300 to 400 ml and he received 2 units of blood and some fresh frozen plasma.",22
"preoperative diagnoses:,1.  torn lateral meniscus, right knee.,2.  chondromalacia of the patella, right knee.,postoperative diagnoses:,1.  torn lateral meniscus, right knee.,2.  chondromalacia of the patella, right knee.,procedure performed:,1.  arthroscopic lateral meniscoplasty.,2.  patellar shaving of the right knee.,anesthesia:  ,general.,complications: , none.,estimated blood loss: , minimal.,total tourniquet time:,  zero.,gross findings: , a complex tear involving the lateral and posterior horns of the lateral meniscus and grade-ii chondromalacia of the patella.,history of present illness: , the patient is a 45-year-old caucasian male presented to the office complaining of right knee pain.  he complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,procedure:  ,after all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  the operative extremity was then confirmed with the operative surgeon, the patient, the department of anesthesia and the nursing staff.,the patient was then transferred to preoperative area to operative suite #2, placed on the operating table in supine position.  department of anesthesia administered general anesthetic to the patient.  all bony prominences were well padded at this time.  the right lower extremity was then properly positioned in a johnson knee holder.  at this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  the right lower extremity was then sterilely prepped and draped in usual sterile fashion.  next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  the cannula and trocar were then inserted through this, putting the patellofemoral joint.  an arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  upon viewing of the patellofemoral joint, there was noted to be grade-ii chondromalacia changes of the patella.  there were no loose bodies noted in the either gutter.  upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  while in this area, attention was directed to establish the inferomedial instrument portal.  this was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  a probe was then inserted through this portal and the meniscus was further probed.  again, there was noted to be no meniscal tear.  the knee was taken through range of motion and there was no chondromalacia.  upon viewing of the femoral notch, there was noted to be intact acl with negative drawer sign.  pcl was also noted to be intact.  upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  it was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  an arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a schlesinger grasper was then used to remove the resected meniscus.  it was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  pictures were taken both pre-meniscal resection and post-meniscal resection.  the arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  the lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  next, attention was directed to the inner surface of the patella.  this was debrided using the 2.5 arthroscopic shaver.  it was noted to be quite smooth and postprocedure the patient was taken ________ well.  the knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% marcaine was then administered to each portal as well as intra-articularly.,sterile dressing was then applied consisting of adaptic, 4x4s, abds, and sterile webril and a stockinette to the right lower extremity.  at this time, department of anesthesia reversed the anesthetic.  the patient was transferred back to the hospital gurney to the postanesthesia care unit.  the patient tolerated the procedure and there were no complications.",37
"mr. abc was transferred to room 123 this afternoon.  we discussed this with the nurses, and it was of course cleared by dr. x.  the patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  he is on his eighth hospital day.,the patient had nasal packing in place, which was removed this evening.  this will make it much easier for him to swallow.  this will facilitate p.o. fluids and imf diet.,examination of the face revealed some decreased swelling today.  he had good occlusion with intact intermaxillary fixation.,his tracheotomy tube is in place.  it is a size 8 shiley nonfenestrated.  he is being suctioned comfortably.,the patient is in need of something for sleep in the evening, so we have recommended halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  hopefully, we can decannulate the tracheotomy tube in the next few days.,overall, i believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.",11
"preoperative diagnosis: , recurrent bladder tumors.,postoperative diagnosis:,  recurrent bladder tumors.,operation: , cystoscopy, tur, and electrofulguration of recurrent bladder tumors.,anesthesia:,  general.,indications: , a 79-year-old woman with recurrent bladder tumors of the bladder neck.,description of procedure:  ,the patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  a #21-french cystourethroscope was inserted into the bladder.  examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  no other lesions were noted.  using a cold punch biopsy forceps, a random biopsy was obtained.  the entire area was electrofulgurated using the bugbee electrode.  the patient tolerated the procedure well and left the operating room in satisfactory condition.",38
"subjective:,  this is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  the patient is in foster care, has a long history of the prematurity, born at 22 weeks.  she has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  she is on 2-1/2 liters of oxygen and does require that.  her diet has been fluctuating.  they have been trying to figure out what works best with her.  she has been on some pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  they have been doing more pureed foods and that seems to loosen her up, so they have been doing more isomil 24 cal and baby foods and not so much pediasure.  she was hospitalized a couple of weeks back for the distension she had in the abdomen.  dr. xyz has been working with her g-tube, increasing her mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her g-tube site is looking.  she also has been seen dr. eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,current medications:,  flagyl, vitamins, zyrtec, albuterol, and some colace.,allergies to medicines: , none.,family social history:,  as mentioned, she is in foster care.  foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  biological mom and grandma do visit on thursdays for about an hour.,review of systems:,  the patient has been eating fairly well, sleeping well, doing well with her sprints.  a little difficulty with her stools hard versus soft as mentioned with the diet situation up in hpi.,physical examination:,vital signs:  she is 28 pounds 8 ounces today, 33-1/2 inches tall.  she is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,heent:  sclerae and conjunctivae are clear.  tms are clear.  nares are patent.  oropharynx is clear.  trach site is clear of any signs of infection.,chest:  coarse.  she has got little bit of wheezing going on, but she is moving air fairly well.,abdomen:  positive bowel sounds and soft.  the g-tube site looks fairly clean today and healthy.  no signs of infection.  her tone is good.  capillary refill is less than three seconds.,assessment:,  a 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,plan:,  at this point is to continue with the isomil and pureed baby foods, a little bit of pediasure.  they are going to see dr. xyz towards the end of this month and follow up with dr. eisenbaum.  i would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  she is just doing wonderful progression on her development.  each time i see her, i am very impressed, that relayed to foster mom.  approximately 25 minutes spent with the patient, most of it counseling.",5
"reason for hospitalization:  ,suspicious calcifications upper outer quadrant, left breast.,history of present illness: , the patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  that study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  additional imaging studies confirmed the suspicious nature of these calcifications.  the patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  the final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  no calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  she underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  i was called to see the patient in the emergency consultation in the breast center.  at the same time, dr. y was consulted in interventional radiology.  dr. z and dr. y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  this resulted in immediate occlusion of the false aneurysm.  the patient was seen in my office for followup appointment on 06/24/08.  at that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  there was, however, no evidence of reforming of the false aneurysm.  there was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,i discussed the issues with the patient and her husband.  the underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  for this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  the patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,the patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  this revealed benign histologic findings.  the family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  other than her age, the patient has no other risk factors for development of breast cancer.  she is not receiving any hormone replacement therapy.  she has had five children with the first pregnancy occurring at the age of 24.  other than her daughter, there are no other family members with breast cancer.  there are no family members with a history of ovarian cancer.,past medical history: , other hospitalizations have occurred for issues with asthma and pneumonia.,past surgical history: , colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,current medications:,1.  plavix.,2.  arava.,3.  nexium.,4.  fosamax.,5.  advair.,6.  singulair.,7.  spiriva.,8.  lexapro.,drug allergies:,  aspirin, penicillin, iodine and codeine.,family history:, positive for heart disease, hypertension and cerebrovascular accidents.  family history is positive for colon cancer affecting her father and a brother.  the patient has a daughter who was diagnosed with breast cancer at age 40.,social history: , the patient does not smoke.  she does have an occasional alcoholic beverage.,review of systems:  ,the patient has multiple medical problems, for which she is under the care of dr. x.  she has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  there is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  the patient has had skin cancers, which have been treated with local excision.,physical examination:,general:  the patient is an elderly aged female who is alert and in no distress.,heent:  head, normocephalic.  eyes, perrl.  sclerae are clear.  mouth, no oral lesions.,neck:  supple without adenopathy.,heart:  regular sinus rhythm.,chest:  fair air entry bilaterally.  no wheezes are noted on examination.,breasts:  normal topography bilaterally.  there are no palpable abnormalities in either breast mound.  nipple areolar complexes are normal.  specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  the previous tissue changes from the stereotactic core needle biopsy have resolved.  axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,abdomen:  obese.  no masses.  normal bowel sounds are present.,back:  no cva tenderness.,extremities:  no clubbing, cyanosis or edema.,assessment:,1.  left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  history of chronic obstructive lung disease and asthma, controlled with medications.,4.  history of gastroesophageal reflux disease, controlled with medications.,5.  history of transient ischemic attack managed with medications.,6.  history of osteopenia and osteoporosis, controlled with medications.,7.  history of anxiety controlled with medications.,plan: , left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  this will be performed on an outpatient basis.",23
"chief complaint:, palpitations.,chest pain / unspecified angina pectoris history:, the patient relates the recent worsening of chronic chest discomfort. the quality of the pain is sharp and the problem started 2 years ago. pain radiates to the back and condition is best described as severe. patient denies syncope. beyond baseline at present time. past work up has included 24 hour holter monitoring and echocardiography. holter showed pvcs.,palpitations history:, palpitations - frequent, 2 x per week. no caffeine, no etoh. + stress. no change with inderal.,valvular disease history:, patient has documented mitral valve prolapse on echocardiography in 1992.,past medical history:, no significant past medical problems. mitral valve prolapse.,family medical history:, cad.,ob-gyn history:, the patients last child birth was 1997. para 3. gravida 3.,social history:, denies using caffeinated beverages, alcohol or the use of any tobacco products.,allergies:, no known drug allergies/intolerances.,current medications:, inderal 20 prn.,review of systems:, generally healthy. the patient is a good historian.,ros head and eyes: denies vision changes, light sensitivity, blurred vision, or double vision.,ros ear, nose and throat: the patient denies any ear, nose or throat symptoms.,ros respiratory: patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ros gastrointestinal: patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ros genitourinary: patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ros gynecological: denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ros musculoskeletal: the patient denies any past or present problems related to the musculoskeletal system.,ros extremities: the patient denies any extremities complaints.,ros cardiovascular: as per hpi.,examination:,exam abdomen/flank: the abdomen is soft without tenderness or palpable masses. no guarding, rigidity or rebound tenderness. the liver and spleen are not palpable. bowel sounds are active and normal.,exam extremities: lower extremities are normal in color, touch and temperature. no ischemic changes are noted.,range of motion is normal. there is no cyanosis, clubbing or edema.,general: healthy appearing, well developed,. the patient is in no acute distress.,exam skin negative to inspection or palpation. there are no obvious lesions or new rashes noted. non-diaphoretic.,exam ears canals are clear. throat is not injected. tonsils are not swollen or injected.,exam neck: there is no thyromegaly, carotid bruits, lymphadenopathy, or jvd. neck is supple.,exam respiratory: normal breath sounds are heard bilaterally. there is no wheezing. there is no use of accessory muscles.,exam cardiovascular: regular heart rate and rhythm, normal s1 and s2 without murmur, gallops or rubs.,impression / diagnosis:, mitral valve prolapse. palpitations.,tests ordered:, cardiac tests: echocardiogram.,medication prescribed:, ,cardizem 30-60 qid prn.",5
"diagnosis: , multiparous female, desires permanent sterilization.,name of operation: , laparoscopic bilateral tubal ligation with falope rings.,anesthesia: , general, et tube.,complications:,  none.,findings:  ,normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,procedure: , the patient was taken to the operating room and placed on the table in the supine position.  after adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  she was found to have an anteverted uterus and no adnexal mass.  she was prepped and draped in the usual fashion.  the foley catheter was placed.  a hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,an infraumbilical incision was made with the knife.  a veress needle was inserted into the abdomen.  intraperitoneal location was verified with approximately 10 cc of sterile solution.  a pneumoperitoneum was created.  the veress needle was then removed, and a trocar was inserted directly without difficulty.  intraperitoneal location was verified visually with the laparoscope.  there was no evidence of any intra-abdominal trauma.,each fallopian tube was elevated with a falope ring applicator, and a falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the falope ring.,the pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  an attempt was made to close the fascia with a figure-of-eight suture.  however, this was felt to be more subcutaneous.  the skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.",37
"preoperative diagnosis: , missed abortion.,postoperative diagnosis:  ,missed abortion.,procedure performed: , suction, dilation, and curettage.,anesthesia: , spinal.,estimated blood loss:,  50 ml.,complications: , none.,findings: , products of conception consistent with a 6-week intrauterine pregnancy.,indications: , the patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  a workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  no heart tones were visible.  on examination in the emergency room, a moderate amount of bleeding was noted.,additionally, the cervix was noted to be 1 cm dilated.  these findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  after discussion of these options, the patient opted for a suction, dilation, and curettage.  the patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  informed consent was obtained prior to proceeding with the procedure.,procedure note:  ,the patient was taken to the operating room where spinal anesthesia was administered without difficulty.  the patient was prepped and draped in usual sterile fashion in lithotomy position.  a weighted speculum was placed.  the anterior lip of the cervix was grasped with a single tooth tenaculum.  at this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  at this time, the suction curette was advanced one additional time to suction any remaining products.  all instruments were removed.  hemostasis was visualized.  the patient was stable at the completion of the procedure.  sponge, lap, and instrument counts were correct.",23
"pre-op diagnoses:,  low back pain - 724.2, herniated disc - 722.10, lumbosacral facet, arthropathy - 724.4.,post-op diagnoses: , low back pain - 724.2, herniated disc - 722.10, lumbosacral facet, arthropathy - 724.4.,interval history:,  plans, risks and options were reviewed with the patient in detail.  the patient understands and agrees to proceed.,anesthesia: , general anesthesia,procedure performed:,  epidural steroid injection, epidurogram, fluroscopy.,procedure:,  after informed consent, the patient was taken to the procedure room and placed in the prone position.  ekg, blood pressure and pulse oximetry were monitored and remained stable throughout the procedure.  the area was prepped and draped in the usual sterile fashion.  local anesthetic was infiltrated at the appropriate level.  fluoroscopic guidance was used to place a #20-gauge tuohy epidural needle gently into the epidural space at l4-l5 using a paramedian approach.  no blood or csf was obtained on aspiration.,radiology: , injection of 3 cc of omnipaque showed spread of the dye into the epidural space on ap and lateral imaging.  the needle was injected with depo-medrol 80 mg with bupivacaine 1/16th , 8 cc total vol.  patient tolerated procedure well and was transferred to recovery room.  patient was discharged home with escort.  discharge instructions were given.,post-op plan:,  i will see the patient back in my office in two weeks.  continue p.r.n. medications as needed.",27
"preoperative diagnosis:,  right breast mass with abnormal mammogram.,postoperative diagnosis:,  right breast mass with abnormal mammogram.,procedure performed:,  right breast excisional biopsy with needle-localization.,anesthesia: , local with sedation.,complications: , none.,specimen: , right breast mass and confirmation by radiology that the specimen was received with the mass was in the specimen.,disposition: , the patient tolerated the procedure well and was transferred to recovery in stable condition.,brief history:  ,the patient is a 41-year-old female who presented to dr. x's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,procedure: , after informed consent, the risks and benefits of the procedure were explained to the patient.  the patient was brought into the operating suite.  after iv sedation was given, the patient was prepped and draped in normal sterile fashion.  a radial incision was made in the right lateral breast with a #10 blade scalpel.  the needle was brought into the field.  an allis was used to grasp the breast mass and breast tissue using the #10 scalpel.  the mass was completely excised and sent out for specimen after confirmation by radiology that the mass was in the specimen.,hemostasis was then obtained with electrobovie cautery.  the skin was then closed with #4-0 monocryl in a running subcuticular fashion.  steri-strips and sterile dressings were applied.  the patient tolerated the procedure well and was transferred to recovery in stable condition.",37
"procedure: , urgent cardiac catheterization with coronary angiogram.,procedure in detail: , the patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal ekg and a cardiac arrest.  the right groin was prepped and draped in usual manner.  under 2% lidocaine anesthesia, the right femoral artery was entered.  a 6-french sheath was placed.  the patient was already on anticoagulation.  selective coronary angiograms were then performed using a left and a 3drc catheter.  the catheters were reviewed.  the catheters were then removed and an angio-seal was placed.  there was some hematoma at the cath site.,results,1.  the left main was free of disease.,2.  the left anterior descending and its branches were free of disease.,3.  the circumflex was free of disease.,4.  the right coronary artery was free of disease.  there was no gradient across the aortic valve.,impression: , normal coronary angiogram.,",12
"preoperative diagnosis (es):, l4-l5 and l5-s1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,postoperative diagnosis (es):, l4-l5 and l5-s1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,procedure:,1. left l4-l5 and l5-s1 transforaminal lumbar interbody fusion (tlif).,2. l4 to s1 fixation (danek m8 system).,3. right posterolateral l4 to s1 fusion.,4. placement of intervertebral prosthetic device (danek capstone spacers l4-l5 and l5-s1).,5. vertebral autograft plus bone morphogenetic protein (bmp).,complications:, none.,anesthesia:, general endotracheal.,specimens:, portions of excised l4-l5 and l5-s1 disks.,estimated blood loss:, 300 ml.,fluids given:, iv crystalloid.,operative indications:, the patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. preoperative imaging studies revealed the above-noted abnormalities. after a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,operative indications, methods, potential benefits, risks and alternatives were reviewed. the patient and his wife expressed understanding and consented to proceed as above.,operative findings:, l4-l5 and l5-s1 disk protrusion with configuration as anticipated from preoperative imaging studies. pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. in addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. spacer snugness and positioning appeared satisfactory. electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,description of the operation:, after obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. after the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by anesthesiology as well as placement of electrophysiological monitoring equipment by the neurology team, the patient was carefully turned to the prone position and placed upon the padded jackson table with appropriate additional padding placed as needed. the patient's posterior lumbosacral region was thoroughly cleansed and shaved. the patient was then scrubbed, prepped and draped in the usual manner. after local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately l3 to the inferior aspect of the sacrum. dissection was continued in the midline to the level of the posterior fascia. self-retaining retractors were placed and subsequently readjusted as needed. the fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from l3-l4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of l4 and l5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. screws were placed in systematic caudal in a cranial fashion. the pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. cortical openings were created at these sites using a small burr. the pedicular tracts were then preliminarily prepared using a lenke pedicle finder. they were then probed and subsequently tapped employing fluoroscopic guidance as needed. each site was ""under tapped"" and reprobed with satisfactory findings noted as above. screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. at s1, 40-mm length screws were placed bilaterally. at l5, 40-mm length screws were placed bilaterally, and at l4, 40-mm length screws were placed bilaterally with findings as noted above. the rod was then contoured to span from the l4 to the s1 screws on the right. the distraction was placed across the l4-l5 interspace, and the connections were temporarily secured. using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. this was longitudinally oriented. a transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the l4 pedicle. this trough was completed to the level of the ligamentum flavum using small angled curettes and kerrison rongeurs, and this portion of the lamina along with the inferior l4 articular process was then removed as a unit using rongeurs and curettes. the cranial aspect of the left l5 superior articular process was then removed using a small burr and angled curettes and kerrison rongeurs. a superior laminotomy was performed from the left l5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and kerrison rongeurs under direct visualization. in this manner, the left lateral aspect of the thecal sac passing left l5 spinal nerve and exiting left l4 spinal nerve along with posterolateral aspect of disk space was exposed. local epidural veins were coagulated with bipolar and divided. gelfoam was then placed in this area. this process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left l5-s1 disk space. as noted, distraction had previously been placed at l4-l5, this was released. distraction was placed across the l5-s1 interspace. after completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the l5-s1 disk space. intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. the disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled tlif curettes to prepare the front plate. herniated portions of the disk were also removed in routine fashion. the diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. after completing this disk space preparation, gelfoam was again placed. the decompression was assessed and appeared to be satisfactory. the distraction was released, and attention was redirected at l4-l5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. after completing the disk space preparation, attention was redirected to l5-s1. distraction was released at l4-l5 and again, reapplied at l5-s1, incrementally increasing size. trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. a medium bmp kit was appropriately reconstituted. a bmp sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. the spacer was then carefully impacted into position. the distraction was released. the spacer was checked with satisfactory snugness and positioning noted. this process was then repeated in similar fashion at l4-l5, again with placement of a 10-mm height by 26-mm length capstone spacer, again containing bmp and again with initial placement of a bmp sponge with vertebral autograft anteriorly within the interspace. this spacer was also checked again with satisfactory snugness and positioning noted. the prior placement of the spacers and bmp, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. surgicel was placed over the exposed dura and disk space. the distraction was released on the right and compression plates across the l5-s1 and l4-l5 interspaces and the connections fully tightened in routine fashion. the posterolateral elements on the right from l4 to s1 were prepared for fusion in routine fashion, and bmp sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the l4-l5 and l5-s1 facets on the right in a routine fashion. a left-sided rod was appropriated contoured and placed to span between the l4 to s1 screws. again compression was placed across the l4-l5 and l5-s1 segments, and these connections were fully secured. thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. the wound was closed using multiple simple interrupted 0-vicryl sutures to reapproximate the deep paraspinal musculature in the midline. the superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-vicryl sutures. the suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 vicryl sutures. the skin was then closed using staples. sterile dressings were then applied and secured in place. the patient tolerated the procedure well and was to the recovery room in satisfactory condition.",26
"procedures,1.  arthroscopic rotator cuff repair.,2.  arthroscopic subacromial decompression.,3.  arthroscopic extensive debridement, superior labrum anterior and posterior tear.,procedure in detail: , after written consent was obtained from the patient, the patient was brought back into the operating room and identified.  the patient was placed on the operating room table in supine position and given general anesthetic.  once the patient was under general anesthetic, a careful examination of the shoulder was performed.  it revealed no patholigamentous laxity.  the patient was then carefully positioned into a beach-chair position.  we maintained the natural alignment of the head, neck, and thorax at all times.  the shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,once we fully prepped and draped, we then began the surgery.  we injected the glenohumeral joint with sterile saline with a spinal needle.  this consisted of 60 cc of fluid.  we then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  we then carefully examined the glenohumeral joint.,we found the articular surface to be in good condition.  there was a superior labral tear (slap).  this was extensively debrided using a shaver through an anterior portal.  we also found a full thickness rotator cuff tear.  we then drained the glenohumeral joint.  we redirected our camera into the subacromial space.  an anterolateral portal was made, both superior and inferior.,we then proceeded to perform a subacromial decompression using high-speed shaver.  the bursa was extensively debrided.  we then abraded the bone over the footprint of where the rotator cuff is usually attached.  the corkscrew anchors were used to perform a rotator cuff repair.  pictures were taken.,through a separate incision, an indwelling pain catheter was then placed.  it was carefully positioned.  pictures were taken.  we then drained the joint.  all instruments were removed.  the patient did receive iv antibiotic preoperatively.  all portals were closed using 4-0 nylon sutures.,xeroform, 4 x 4s, and opsite were applied over the pain pump.  abd, tape, and a sling were also applied.  a cryo/cuff was also placed over the shoulder.  the patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  the patient was extubated and brought to the recovery room in stable condition.  i then went out and spoke with the family, going over the case, postoperative instructions, and followup care.",37
"preoperative diagnoses:,  bladder cancer and left hydrocele.,postoperative diagnoses: , bladder cancer and left hydrocele.,operation:  ,left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,anesthesia:,  spinal.,estimated blood loss:  ,minimal.,fluids:,  crystalloid.,brief history:  ,the patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected.  he has received bcg.  the patient is doing well.  the patient was supposed to come to the or for surveillance biopsy and pyelograms.  the patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc.  options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed.  risks of anesthesia, bleeding, infection, pain, mi, dvt, pe, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed.  the patient understood all the options and wanted to proceed with the procedure.,procedure in detail: , the patient was brought to the or.  anesthesia was applied.  the patient was placed in dorsal lithotomy position.  the patient was prepped and draped in usual sterile fashion.,a transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn.  the sac was turned upside down and sutures were placed.  careful attention was made to ensure that the cord was open.  the testicle was in normal orientation throughout the entire procedure.  the testicle was placed back into the scrotal sac and was pexed with 4-0 vicryl to the outside dartos to ensure that there was no risk of torsion.  orchiopexy was done at 3 different locations.  hemostasis was obtained using electrocautery.  the sac was closed using 4-0 vicryl.  the sac was turned upside down so that when it heals, the fluid would not recollect.  the dartos was closed using 2-0 vicryl and the skin was closed using 4-0 monocryl and dermabond was applied.  incision measured about 2 cm in size.  subsequently using acmi cystoscope, a cystoscopy was performed.  the urethra appeared normal.  there was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder.  there was a short prostatic fossa.  the bladder appeared normal.  there was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance.  there were no papillary tumors or stones inside the bladder.  bilateral pyelograms were obtained using 8-french cone-tip catheter, which appeared normal.  a cold cup biopsy of the bladder was done and was fulgurated for hemostasis.  the patient tolerated the procedure well.  the patient was brought to recovery at the end of the procedure after emptying the bladder.,the patient was given antibiotics and was told to take it easy.  no heavy lifting, pushing, or pulling.  plan was to follow up in about 2 months.",37
"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.",37
"preoperative diagnosis:  ,lumbar radiculopathy, 724.4.,postoperative diagnosis:,  lumbar radiculopathy, 724.4.,procedure:,  lumbar epidural steroid injection.,anesthesiologist:,  monitored anesthesia care,injectate used:,  10 ml of 0.5% lidocaine and 80 mg of depo-medrol.,estimated blood loss:,  none.,complications:,  none.,details of the procedure:,  the patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained.  a thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death.  there were no known ekg, chest x-ray, or laboratory contraindications to the procedure.,the patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury.  arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,the l4-l5 interspace was identified fluoroscopically.  a left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,a number #18-gauge tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of l5.  needle tip position was confirmed in the anterior posterior fluoroscopic view.  the epidural space was located with the loss of pulsation technique.  aspiration of the syringe was negative for blood or cerebrospinal fluid.  one millimeter of 0.9% preservative was injected with good loss resistance noted.,discharge summary:,  following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.",27
"reason for visit:  ,the patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  she comes to clinic by herself.,history of present illness: , dr. x has cared for her since 2002.  she has a codman-hakim shunt set at 90 mmh2o.  she last saw us in clinic in january 2008 and at that time we recommended that she followup with dr. y for medical management of her chronic headaches.  we also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an mri on 04/18/08.  she states that since that time her headaches have been bad.  they woke her up at night.  she has not been able to sleep.  she has not had a good sleep cycle since that time.  she states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  she states that they feel a little bit better when lying down.  medication shave not helped her.  she has tried taking imitrex as well as motrin 800 mg twice a day, but she states it has not provided much relief.  the pain is generalized, but also noted to be quite intense in the frontal region of her head.  she also reports ringing in the ears and states that she just does not feel well.  she reports no nausea at this time.  she also states that she has been experiencing intermittent blurry vision and dimming lights as well.  she tells me that she has an appointment with dr. y tomorrow.  she reports no other complaints at this time.,major findings:,  on examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  she is well developed, well nourished, and kempt.,vital signs:  blood pressure 153/86, pulse 63, and respiratory rate 16.,cranial nerves:  intact for extraocular movements.  facial movement, hearing, head turning, tongue, and palate movements are all intact.  i did not know any papilledema on exam bilaterally.,i examined her shut site, which is clean, dry, and intact.  she did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  it looks like there is a little bit of dry blood there.,assessment:,  the patient appears to have had worsening headaches since shunt adjustment back after an mri.,problems/diagnoses:,1.  pseudotumor cerebri without papilledema.,2.  migraine headaches.,procedures:,  i programmed her shunt to 90 mmh2o.,plan:,  it was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  i had programmed her shunt back to 90 mmh2o at that time and confirmed it with an x-ray.  however, the picture of the x-ray was not the most desirable picture.  thus, i decided to reprogram the shunt back to 90 mmh2o today and have the patient return to sinai for a skull x-ray to confirm the setting at 90.  in addition, she told me that she is scheduled to see dr. y tomorrow, so she should followup with him and also plan on contacting the wilmer eye institute to setup an appointment.  she should followup with the wilmer eye institute as she is complaining of blurry vision and dimming of the lights occasionally.,total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.",5
"preoperative diagnoses:,1.  chronic nasal obstruction secondary to deviated nasal septum.,2.  inferior turbinate hypertrophy.,postoperative diagnoses:,1.  chronic nasal obstruction secondary to deviated nasal septum.,2.  inferior turbinate hypertrophy.,procedure performed:,1.  nasal septal reconstruction.,2.  bilateral submucous resection of the inferior turbinates.,3.  bilateral outfracture of the inferior turbinates.,anesthesia:,  general endotracheal tube.,blood loss: , minimal less than 25 cc.,indications: , the patient is a 51-year-old female with a history of chronic nasal obstruction.  on physical examination, she was derived to have a severely deviated septum with an s-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,procedure:  ,after all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  the patient was brought to the operating suite where she was placed in the supine position and general endotracheal intubation was delivered by the department of anesthesia.  the patient was rotated 90 degrees away.  nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities.  these were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution.  the nasal pledgets were then reinserted as the patient was prepped in the usual fashion.  the nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% marcaine solution.  the nasal vestibules were then cleansed with a phisohex solution.  a #15 blade scalpel was then used to make an incision along the length of the caudal septum.  the mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor.  once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a cottle.  at this point it should be mentioned that the patient's septum was significantly deviated with a large s-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity.  again, the cottle elevator was used to raise the mucosal flap down to the level of the septal spur.  at this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur.  again, the mucosal flap was elevated in the right nasal septum.  now knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a takahashi forceps.  a cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side.  removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel.  once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms.  therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone.  the xps microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone.  once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages.  inspection revealed very patent and nonobstructive nasal passages.  now the caudal incision was reapproximated with #4-0 chromic suture.  finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion.  finally, merocel packing was placed and the patient was retuned to the department of anesthesia for awakening and taken to the recovery room without incident.",11
"history of present illness: , the patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  she had an egd and colonoscopy with dr. abc a few days prior to this admission.  colonoscopy did reveal diverticulosis and egd showed retained bile and possible gastritis.  biopsies were done.  the patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,past medical history: , extensive and well documented in prior charts.,physical examination: , abdomen was diffusely tender.  lungs clear.  blood pressure 129/69 on admission.  at the time of admission, she had just a trace of bilateral lower edema.,laboratory studies: , white count 6.7, hemoglobin 13, hematocrit 39.3.  potassium of 3.2 on 08/15/2007.,hospital course: , dr. abc apparently could not advance the scope into the cecum and therefore warranted a barium enema.  this was done and did not really show what the cecum on the barium enema.  there was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  she did have some enemas.  she had persistent nausea, headache, neck pain throughout this hospitalization.  finally, she did improve enough to the point where she could be discharged home.,discharge diagnosis: , nausea and abdominal pain of uncertain etiology.,secondary diagnosis:  ,migraine headache.,complications:  ,none.,discharge condition: , guarded.,discharge plan:  ,follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  diet and activity as tolerated.",15
"subjective: , this patient presents to the office today because of some problems with her right hand.  it has been going tingling and getting numb periodically over several weeks.  she just recently moved her keyboard down at work.  she is hoping that will help.  she is worried about carpal tunnel.  she does a lot of repetitive type activities.  it is worse at night.  if she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  it involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  she has some pain in her thumb as well.  she thinks that could be arthritis.,objective: , weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  general:  the patient is nontoxic and in no acute distress.  musculoskeletal:  the right hand was examined.  it appears to be within normal limits and the appearance is similar to the left hand.  she has good and equal grip strength noted bilaterally.  she has negative tinel's bilaterally.  she has a positive phalen's test.  the fingers on the right hand are neurovascularly intact with a normal capillary refill.,assessment:  ,numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  i suspect carpal tunnel syndrome.,plan:  ,the patient is going to use anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  we are going to try this for two weeks and if the condition is still present, then we are going to proceed with emg test at that time.  she is going to let me know.  while she is here, i am going to also get her the blood test she needs for her diabetes.  i am noting that her blood pressure is elevated, but improved from the last visit.  i also noticed that she has lost a lot of weight.  she is working on diet and exercise and she is doing a great job.  right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and i expect the blood pressure will continue to improve.",34
"identifying data:  ,mr. t is a 45-year-old white male.,chief complaint: , mr. t presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  his confidence and self-esteem are significantly low.  he stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  he has had suicidal ideation, but this is currently in remission.  furthermore, he continues to have hopeless thoughts and crying spells.  mr. t stated these symptoms appeared approximately two months ago.,history of present illness: , on march 25, 2003, mr. t was fired from his job secondary, to an event at which he stated he was first being harassed by another employee."" this other, employee had confronted mr. t with a very aggressive, verbal style, where this employee had placed his face directly in front of mr. t was spitting on him, and called him ""bitch."" mr. t then retaliated, and went to hit the other employee.  due to this event, mr. t was fired.  it should be noted that mr. t stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to ""deal with it."",there are no other apparent stressors in mr. t's life at this time or in recent months.  mr. t stated that work was his entire life and he based his entire identity on his work ethic.  it should be noted that mr. t was a process engineer for plum industries for the past 14 years.,past psychiatric history:,  there is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to mr. t's family physician, dr. b at which point mr. t was placed on lexapro with an unknown dose at this time.  mr. t is currently seeing dr. j for psychotherapy where he has been in treatment since april, 2003.,past psychiatric review of systems:,  mr. t denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  he denied any suicide attempts, or profound suicidal or homicidal ideation.  mr. t furthermore stated that his family psychiatric history is unremarkable.,substance abuse history:,  mr. t stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  no other substance abuse was noted.,legal history: , currently, charges are pending over the above described incident.,medical history: , mr. t denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,personal and social history: , mr. t was born in dwyne, missouri, with no complications associated with his birth.  originally, he was raised by both parents, but they separated at an early age.  when he was about seven years old, he was raised by his mother and stepfather.  he did not sustain a relationship with his biological father from that time on.  he stated his parents moved a lot, and because this many times he was picked on in his new environments, mr. t stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,mr. t stated his stepfather was somewhat verbally abusive, and that he committed suicide when mr. t was 18 years old.  he graduated from high school and began work at dana corporation for two to three years, after which he worked as an energy, auditor for a gas company.  he then became a homemaker while his wife worked for chrysler for approximately two years.  mr. t was married for eleven years, and divorced in 1993.  he has a son who is currently 20 years old.  after being a home maker, mr. t worked for his mother in a restaurant, and moved on from there to work for borg-warner corporation for one to two years before beginning at plum industries, where he worked for 14 years and worked his way up to lead engineer.,mental status exam:  mr. t presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  at times he showed some involuntary movements that would be more akin to a resting tremor.  there was no psychomotor retardation, but there was some mild psychomotor excitement.  his speech was clear, concise, but pressured.  his attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  there was no evidence of euphoria or diurnal mood variation.  his affective expression was restricted range, but there was no evidence of lability.  at times, his affective tone and facial expressions were inappropriate to the interview.  there was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  there was no evidence of illusions, depersonalizations, or derealizations.  mr. t presented with a sequential and goal directed stream of thought.  there was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  there was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  there was evidence of concreteness for similarities and proverbs.  his intelligence was average.  his concentration was mildly impaired, and there was no evidence of distractibility.  he was oriented to time, place, person and situation.  there was no evidence of clouded consciousness or dissociation.  his memory was intact for immediate, recent, and remote events.,he presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  there was a moderate preoccupation with his physical health pertaining to his headaches.  his judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  mr. t's insight is somewhat moderate as he is aware of his contribution to the problem.  his motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  he has a well-developed empathy for others and capacity for affection.,there was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  his credibility seemed good.  there was no evidence for potential self-injury, suicide, or violence.  the reliability and completeness of information was very good, and there were no barriers to communication.  the information gathered was based on the patient's self-report and objective testing and observation.  his attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  there was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,impressions: , major depressive disorder, single episode,recommendations and plan: , i recommend mr. t continue with psychopharmacologic care as well as psychotherapy.  at this time, the excessive amount of psychiatric symptoms would impede mr. t from seeking employment.  furthermore, it appears that the primary precipitating event had occurred on march 25, 2003, when mr. t was fired from his job after being harassed for over a year.  as mr. t placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  furthermore, it only appears logical that this would precipitate a major depressive episode.",18
"preoperative diagnoses:,1.  left carpal tunnel syndrome.,2.  stenosing tenosynovitis of right middle finger (trigger finger).,postoperative diagnoses:,1.  left carpal tunnel syndrome.,2.  stenosing tenosynovitis of right middle finger (trigger finger).,procedures:,1.  endoscopic release of left transverse carpal ligament.,2.  steroid injection, stenosing tenosynovitis of right middle finger.,anesthesia:  ,monitored anesthesia care with regional anesthesia applied by surgeon.,tourniquet time: , left upper extremity was 15 minutes.,operative procedure in detail:,  with the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  the arm was exsanguinated.  the tourniquet was elevated at 290 mmhg.  construction lines were made on the left palm to identify the ring ray.  a transverse incision was made in the palm between fcr and fcu, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  blunt dissection exposed the antebrachial fascia.  hemostasis was obtained with bipolar cautery.  a distal based window in the antebrachial fascia was then fashioned.  care was taken to protect the underlying contents.  a synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,hamate sounds were then used to palpate the hood of hamate.  the agee inside job was then inserted into the proximal incision.  the transverse carpal ligament was easily visualized through the portal.  using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  the distal end of the transverse carpal ligament was then identified in the window.  the blade was then elevated, and the agee inside job was withdrawn, dividing transverse carpal ligament under direct vision.  after complete division of transverse carpal ligament, the agee inside job was reinserted.  radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  one ml of celestone was then introduced into the carpal tunnel and irrigated free.  ,the wound was then closed with a running 3-0 prolene subcuticular stitch.  steri-strips were applied and a sterile dressing was applied over the steri-strips.  the tourniquet was deflated.  the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 ml of 1% plain xylocaine and 0.5 ml of depo-medrol 40 mg/ml.  a band-aid dressing was then applied.,the patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.",37
"preoperative diagnosis: , right upper eyelid squamous cell carcinoma.,postoperative diagnosis: , right upper eyelid squamous cell carcinoma.,procedure performed: , excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,complications:  ,none.,blood loss: , minimal.,anesthesia:,  local with sedation.,indication:,  the patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,description of procedure: , the patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion.  he was anesthetized with a combination of 2% lidocaine and 0.5% marcaine with epinephrine on both upper eyelids.  the area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes.  this was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid.  the resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact.  following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate.  the specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma.  meticulous hemostasis was obtained with bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid.  the left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures.  an eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to pacu in good condition.",25
"reason for visit:  ,followup cervical spinal stenosis.,history of present illness:  ,ms. abc returns today for followup regarding her cervical spinal stenosis.  i have last seen her on 06/19/07.  her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,i referred her to obtain a cervical spine mri.,she returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  she had some physical therapy, which has been helping with the neck pain.  the right hand weakness continues.  she states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  she states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,she has been undergoing nonoperative management by dr. x and feels this has been helping her neck pain, but not the upper extremity symptoms.,she denies any bowel and bladder dysfunction.  no lower back pain, no lower extremity pain, and no instability with ambulation.,review of systems:,  negative for fevers, chills, chest pain, and shortness of breath.,findings:  ,on examination, ms. abc is a very pleasant well-developed, well-nourished female in no apparent distress.  alert and oriented x3.  normocephalic and atraumatic.  afebrile to touch.,she ambulates with a normal gait.,motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,light touch sensation decreased in the right greater than left c6 distribution.  biceps and brachioradialis reflexes are 3 plus.  hoffman sign normal bilaterally.,lower extremity strength is 5 out of 5 in all muscle groups.  patellar reflex is 3 plus.  no clonus.,cervical spine radiographs dated 06/21/07 are reviewed.,they demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at c4-5, c5-6, c6-7, and c3-4 demonstrates only minimal if any degenerative disk disease.  there is no significant instability seen on flexion-extension views.,updated cervical spine mri dated 06/21/07 is reviewed.,it demonstrates evidence of moderate stenosis at c4-5, c5-6.  these stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the c6-7 level.  minimal degenerative disk disease is seen at the c6-7.  this stenosis is greater than c5-6 and the next level is more significantly involved at c4-5.,effacement of the ventral and dorsal csf space is seen at c4-5, c5-6.,assessment and plan: , ms. abc's history, physical examination, and radiographic findings are compatible with c4-5, c5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,i spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,i laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,the patient states she would like to avoid injections and is somewhat afraid of having these done.  i explained to her that they may help to improve her symptoms, although they may not help with the weakness.,she feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,i described the procedure consisting of c4-5, c5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,i explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  she understands.,i discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,i also discussed the option of disk arthroplasty.  she understands.,she would like to proceed with the surgery, relatively soon.  she has her birthday coming up on 07/20/07 and would like to hold off, until after then.  our tentative date for the surgery is 08/01/07.  she will go ahead and continue the preoperative testing process.",26
"chief complaint: , left flank pain and unable to urinate.,history: , the patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating.  details are in the history and physical.  she does have a vague history of a bruised left kidney in a motor vehicle accident.  she feels much better today.  i was consulted by dr. x.,medications:,  ritalin 50 a day.,allergies: , to penicillin.,past medical history: , adhd.,social history:,  no smoking, alcohol, or drug abuse.,physical examination: , she is awake, alert, and quite comfortable.  abdomen is benign.  she points to her left flank, where she was feeling the pain.,diagnostic data: , her cat scan showed a focal ileus in left upper quadrant, but no thickening, no obstruction, no free air, normal appendix, and no kidney stones.,laboratory work: , showed white count 6200, hematocrit 44.7.  liver function tests and amylase were normal.  urinalysis 3+ bacteria.,impression:,1.  left flank pain, question etiology.,2.  no evidence of surgical pathology.,3.  rule out urinary tract infection.,plan:,1.  no further intervention from my point of view.,2.  agree with discharge and followup as an outpatient.  further intervention will depend on how she does clinically.  she fully understood and agreed.",5
"reason for visit: , follow up consultation, second opinion, foreskin.,history of present illness: , a 2-week-old who at this point has otherwise been doing well.  he has a relatively unremarkable foreskin.  at this point in time, he otherwise seems to be doing reasonably well.  the question is about the foreskin.  he otherwise has no other significant issues.  severity low, ongoing since birth two weeks.  thank you for allowing me to see this patient in consultation.,physical examination:,  male exam.  normal and under the penis, report normal uncircumcised 2-week-old.  he has a slightly insertion on the penile shaft from the median raphe of the scrotum.,impression: , slightly high insertion of the median raphe.  i see no reason he cannot be circumcised as long as they are careful and do a very complete gomco circumcision.  this kid should otherwise do reasonably well.,plan:  ,follow up as needed.  but my other recommendation is that this kid as i went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a gomco circumcision.",38
"preoperative diagnosis: , recurrent degenerative spondylolisthesis and stenosis at l4-5 and l5-s1 with l3 compression fracture adjacent to an instrumented fusion from t11 through l2 with hardware malfunction distal at the l2 end of the hardware fixation.,postoperative diagnosis: , recurrent degenerative spondylolisthesis and stenosis at l4-5 and l5-s1 with l3 compression fracture adjacent to an instrumented fusion from t11 through l2 with hardware malfunction distal at the l2 end of the hardware fixation.,procedure: , lumbar re-exploration for removal of fractured internal fixation plate from t11 through l2 followed by a repositioning of the l2 pedicle screws and evaluation of the fusion from t11 through l2 followed by a bilateral hemilaminectomy and diskectomy for decompression at l4-5 and l5-s1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the capstone system at l4-5 and l5-s1 followed by placement of the pedicle screw fixation devices at l3, l4, l5, and s1 and insertion of a 20 cm fixation plate that range from the t11 through s1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at l1-2 and then at l3-l4, l4-l5, and l5-s1 bilaterally.,description of procedure:  ,this is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from t11 through l2.  she subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  there was no evidence of infection on the imaging or with her laboratory studies.  in addition, she developed a pretty profound stenosis at l4-l5 and l5-s1 that appeared to be recurrent as well.  she now presents for revision of her hardware, extension of fusion, and decompression.,the patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  she was placed on the operative table in the prone position.  back was prepared with betadine, iodine, and alcohol.  we elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  the locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  after these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  we then dressed the l4-l5 and l5-s1 levels which were profoundly stenotic.  this was a combination of scar and overgrown bone.  she had previously undergone bilateral hemilaminectomies at l4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  after completing this, we inserted the capstone interbody spacer filled with morselized autograft bone and some bmp sponge into the disk space at both levels.  we used 10 x 32 mm spacers at both l4-l5 and l5-s1.  this corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of l4, l5 and s1 tightened the pedicle screws in l3.  this allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from s1 up to the t11 level.  once we placed the plate onto the screws and locked them in position, we then packed the remaining bmp sponge and morselized autograft bone through the plate around the incomplete fracture healing at the l1 level and then dorsolaterally at l4-l5 and l5-s1 and l3-l4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  the wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  prior to closing the skin, we confirmed correct sponge and needle count.  we placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  the cell saver blood was recycled and she was given two units of packed red blood cells as well.  i was present for and performed the entire procedure myself or supervised.",26
"technique: , sequential axial ct images were obtained from the vertex to the skull base without contrast.,findings: , there is mild generalized atrophy.  scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  the brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  the visualized paranasal sinuses and mastoid air cells are clear.  the bony calvarium and skull base are within normal limits.  ,impression: , no acute abnormalities.",21
"findings:,there is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle, extending to the olecranon process and along the superficial aspect of the epicondylo-olecranon ligament. there is no demonstrated solid, cystic or lipomatous mass lesion. there is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel. there is inflammation with mild laxity of the epicondylo-olecranon ligament. the combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. there is no accessory muscle within the cubital tunnel. the common flexor tendon origin is normal.,normal ulnar collateral ligamentous complex.,there is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear.,there is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis. there is no demonstrated common extensor tendon tear. normal radial collateral ligamentous complex.,normal radiocapitellum and ulnotrochlear articulations.,normal triceps and biceps tendon insertions.,there is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon.,impression:,edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo-olecranon ligament.,enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis.,the above combined findings suggest a subluxing ulnar nerve.,mild epimysial sheath strain of the pronator teres muscle but no muscular tear.,mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon.,peritendinous edema of the brachialis tendon insertion.,no solid, cystic or lipomatous mass lesion.,",26
"preoperative diagnosis:,  displaced left subtrochanteric femur fracture.,postoperative diagnosis:,  displaced left subtrochanteric femur fracture.,operation: , intramedullary rod in the left hip using the synthes trochanteric fixation nail measuring 11 x 130 degrees with an 85-mm helical blade.,complications:,  none.,tourniquet time:,  none.,estimated blood loss:,  50 ml.,anesthesia: , general.,indications:  ,the patient suffered a fall at which time she was taken to the emergency room with pain in the lower extremities.  she was diagnosed with displaced left subcapital hip fracture, now was asked to consult.  with this diagnosis, she was indicated the above-noted procedure.  this procedure as well as alternatives to this procedure was discussed at length with the patient and her son, who has the power of attorney, and they understood them well.,risks and benefits were also discussed.  risks include bleeding, infection, damage to blood vessels, damage to nerves, risk of further surgery, chronic pain, restricted range of motion, risk of continued discomfort, risk of malunion, risk of nonunion, risk of need for further reconstructive procedures, risk of need for altered activities and altered gait, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  she understood these well and consented, and the son signed the consent for the procedure as described.,description of procedure: , the patient was placed on the operating table and general anesthesia was achieved.  the patient was then placed in fracture boots and manipulated under fluoroscopic control until we could obtain near anatomic alignment.  external positions were felt to be present.  at this point, the left hip and left lower extremity was then prepped and draped in the usual sterile manner.  a guidewire was then placed percutaneously into the tip of the greater trochanter and a small incision was made overlying the guidewire.  an overlying drill was inserted to the proper depths.  a synthes 11 x 130 degrees trochanteric fixation that was chosen was placed into the intramedullary canal to the proper depth.  proper rotation was obtained and the guide for the helical blade was inserted.  a small incision was made for this as well.  a guidewire was inserted and felt to be in proper position, in the posterior aspect of the femoral head, lateral, and the center position on ap.  this placed the proper depths and lengths better.  the outer cortex was enlarged and an 85-mm helical blade was attached to the proper depths and proper fixation was done.  appropriate size screw was then tightened down.  at this point, a distal guide was then placed and drilled across both the cortices.  length was better.  appropriate size screw was then inserted.  proper size and fit of the distal screw was also noted.  at this point, on fluoroscopic control, it was confirming in ap and lateral direction.  we did a near anatomical alignment to the fracture site and all hardware was properly fixed.  proper size and fit was noted.  excellent bony approximation was noted.  at this point, both wounds were thoroughly irrigated, hemostasis confirmed, and closure was then begun.,the fascial layers were then reapproximated using #1 vicryl in a figure-of-eight manner, the subcutaneous tissues were reapproximated in layers using #1 and 2-0 vicryl sutures, and the skin was reapproximated with staples.  the area was then infiltrated with a mixture of a 0.25% marcaine with epinephrine and 1% plain lidocaine.  sterile dressing was then applied.  no complication was encountered throughout the procedure.  the patient tolerated the procedure well.  the patient was taken to the recovery room in stable condition.",26
"preoperative diagnoses,1.  recurrent tonsillitis.,2.  deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  residual adenoid hypertrophy and recurrent epistaxis.,postoperative diagnoses,1.  recurrent tonsillitis.,2.  deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  residual adenoid hypertrophy and recurrent epistaxis.,final diagnoses,1.  recurrent tonsillitis.,2.  deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  residual adenoid hypertrophy and recurrent epistaxis.,operation performed,1.  tonsillectomy and adenoidectomy.,2.  left superficial nasal cauterization.,description of operation:,  the patient was brought to the operating room.  endotracheal intubation carried out by dr. x. the mcivor mouth gag was inserted and gently suspended.  afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  the hypertrophic tonsils were then removed by the suction and snare.  deeply cryptic changes as expected were evident.  bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  an inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  they were shaved back, flushed with prevertebral fascia with curette.  hemostasis established with packing followed by electrocautery.  in light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  a nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  the bleeding was admittedly a bit of a annoyance.  an additional control was established by infiltrating slowly with a 1% xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  no additional bleeding was then evident.  the oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  discharge will be anticipated later in the day on lortab plus amoxicillin plus ponaris nose drops.  office recheck anticipated if stable and doing well in three to four weeks.",11
"reason for referral:,  the patient is a 58-year-old african-american right-handed female with 16 years of education who was referred for a neuropsychological evaluation by dr. x. she is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the ""early stages of a likely dementia"" and was thereafter terminated from her position as a psychiatric nurse.  a comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.  note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning.  the patient was fully informed about the nature of this evaluation and intended use of the results.,relevant background information:  ,historical information was obtained from a review of available medical records and clinical interview with the patient.  a summary of pertinent information is presented below.  please refer to the patient's medical chart for a more complete history.,history of presenting problem:,  the patient reported that she had worked as a nurse supervisor for hospital center for four years.  she was dismissed from this position in september 2009, although she said that she is still under active status technically, but is not able to work.  she continues to receive some compensation through fmla hours.  she said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from state services.  she said that these 90 days are up around the end of november.  she said the reason for her dismissal was performance complaints.  she said that they began ""as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off.  she said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays.  she described it as a very chaotic and hectic work environment in which she was often putting in extra time.  she said that since september 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,in july of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time.  following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, dr. y, ph.d.  he completed a comprehensive independent medical evaluation on 08/14/2009.  she said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore.  please note that we do not have copies of any of her work-related correspondence.  the patient never received a copy of the neuropsychological evaluation because she was told that it was ""too derogatory.""  a copy of that evaluation was provided directly to this examiner for the purpose of this evaluation.  to summarize, the results indicated ""diagnostically, the patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history.  this suggests that her intellectual functioning has declined.""  it concluded that ""results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy…  the patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing.  the prognosis for improvement is not good, although she might try stimulant medication if compatible with her other.  following her dismissal, the patient presented to her primary physician, henry fein, m.d., who referred her to dr. x for a second opinion regarding her cognitive deficits.  his neurological examination on 09/23/2009 was unremarkable.  the patient scored 20/30 on the mini-mental status exam missing one out of three words on recall, but was able to do so with prompting.  a repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,imaging studies: , mri of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions.  note that the mri was done with and without gadolinium contrast.,current functioning:  ,the patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her.  when asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills.  she also denied any problems with attention and concentration or forgetfulness or memory problems.  she continues to independently perform all activities of daily living.  she is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning.  she reported that if her children had noticed anything they definitely would have brought it to her attention.  she said that she does not currently have a lawyer and does not intend to return to her previous physician.  she said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application.  other current symptoms include excessive fatigue.  she reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia.  she also reported having fallen approximately five times within the past year.  she said that this typically occurs when she is climbing up steps and is usually related to her right foot ""like dragging.""  dr. x's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis.  she said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body.  muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,other medical history: , the patient reported that her birth and development were normal.  she denied any significant medical conditions during childhood.  as mentioned, she now has a history of fibromyalgia.  she also experiences some restriction in the range of motion with her right arm.  mri of the c-spine 04/02/2009 showed a hemangioma versus degenerative changes at c7 vertebral body and bulging annulus with small central disc protrusion at c6-c7.  mri of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon.  as mentioned, she was diagnosed with chronic fatigue syndrome in 1991.  she thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control.  she also has diabetes, high blood pressure, osteoarthritis, tension headaches, gerd, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974.  her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007.  she has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night.  she did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,current medications:,  novolog, insulin pump, metformin, metoprolol, amlodipine, topamax, lortab, tramadol, amitriptyline, calcium plus vitamin d, fluoxetine, pantoprazole, naprosyn, fluticasone propionate, and vitamin c.,substance use: , the patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs.  she drinks two to four cups of coffee per day.,social history:  ,the patient was born and raised in north carolina.  she was the sixth of nine siblings.  her father was a chef.  he completed third grade and died at 60 due to complications of diabetes.  her mother is 93 years old.  her last job was as a janitor.  she completed fourth grade.  she reported that she has no cognitive problems at this time.  family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression.  the patient completed a bachelor of science in nursing through state university in 1979.  she denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems.  she was married for two years.  her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse.  she has two children ages 43 and 30.  her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in new york.  in school, the patient reported obtaining primarily a's and b's.  she said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling.  the patient worked for hospital center for four years.  prior to that, she worked for an outpatient mental health center for 2-1/2 years.  she was reportedly either terminated or laid off and was unsure of the reason for that.  prior to that, she worked for walter p. carter center reportedly for 21 years.  she has also worked as an ob nurse in the past.  she reported that other than the two instances reported above, she had never been terminated or fired from a job.  in her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,psychiatric history: , the patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue.  she was also taking prozac during that time.  she then began taking prozac again when she started working at secondary to stress with the work situation.  she reported a chronic history of mild sadness or depression, which was relatively stable.  when asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things.  she denied any history of suicidal ideation or homicidal ideation.,tasks administered:,clinical interview,adult history questionnaire,wechsler test of adult reading (wtar),mini mental status exam (mmse),cognistat neurobehavioral cognitive status examination,repeatable battery for the assessment of neuropsychological status (rbans; form xx),mattis dementia rating scale, 2nd edition (drs-2),neuropsychological assessment battery (nab),wechsler adult intelligence scale, third edition (wais-iii),wechsler adult intelligence scale, fourth edition (wais-iv),wechsler abbreviated scale of intelligence (wasi),test of variables of attention (tova),auditory consonant trigrams (act),paced auditory serial addition test (pasat),ruff 2 & 7 selective attention test,symbol digit modalities test (sdmt),multilingual aphasia examination, second edition (mae-ii), token test, sentence repetition, visual naming, controlled oral word association, spelling test, aural comprehension, reading comprehension,boston naming test, second edition (bnt-2),animal naming test",21
"preoperative diagnoses: , bilateral cleft lip and bilateral cleft of the palate.,postoperative diagnoses: , bilateral cleft lip and bilateral cleft of the palate.,procedure performed: , repair of bilateral cleft of the palate with vomer flaps.,estimated blood loss: , 40 ml.,complications: , none.,anesthesia: , general endotracheal anesthesia.,condition of the patient at the end of the procedure:,  stable, extubated, and transferred to the recovery room in stable condition.,indications for procedure:  ,the patient is a 10-month-old baby with a history of a bilateral cleft of the lip and palate.  the patient has undergone cleft lip repair, and she is here today for her cleft palate operation.  we have discussed with the mother the nature of the procedure, risks, and benefits; the risks included but not limited to the risk of bleeding, infection, dehiscence, scarring, the need for future revision surgeries.  we will proceed with surgery.,details of the procedure:,  the patient was taken into the operating room, placed in the supine position, and general anesthetic was administered.  a prophylactic dose of antibiotics was given.  the patient proceeded to have bilateral pe tube placement by dr. x, from ear, nose, and throat surgery.  after he was done with his procedure, the head of the bed was turned 90 degrees.  the patient was positioned with a shoulder roll and doughnut.  a dingman retractor was placed.  the operative area was infiltrated with lidocaine with epinephrine 1:200,000, a total of 3 ml, and then, i proceeded with the prepping and draping.  the patient was prepped and draped.  i proceeded to do the palate repair.  the nature of the palate repair was done in the same way on the both sides.  i will describe one side.  the other side was done exactly in the same manner.  the 2 hemiuvulas are placed, holding from a single hook and infiltrated with lidocaine with epinephrine 1:200,000, triangle in the nasal mucosa was previously marked.  this triangle of nasal mucosa was removed and excised.  this was done on both uvulas.  then, an incision was done at the level of the palatal cleft at the junction of the nasal and oral mucosa.  a 1-mm cuff of oral mucosa was used to be able to approximate the nasal mucosa better.  once the incision was done up to the level of the hard palate, the muscle was dissected off the surrounding tissue, 2 mm from the nasal and the oral mucosa.  then, i proceeded to place an incision at the alveolopalatal junction with the help of 15-blade.  the incision starts at the maxillary tuberosity posteriorly and comes anteriorly at the alveolopalatal junction through the full thickness of mucoperiosteal flap.  then the flap was lifted up with the help of a freer, and then the remaining of the incision medially was completed.  hemostasis was achieved with help of electrocautery and surgicel.  the mucoperiosteal flap was retracted posteriorly with the help of a freer elevator.  the greater auricular foramen was exposed, and the pedicle skeletonized to allow medial retraction of the mucoperiosteal flap.  then an osteotomy was done at the level of the greater auricular foramen to allow mobilization of the pedicle medially as well as a small incision was done in the periosteum around the pedicle.  the pedicle carefully dissected to allow better mobilization of the mucoperiosteal flap medially.  this procedure was done on both sides in the same manner, and then __________ dissection was done including dissection of the hard palate from the nasal mucosa, it was evident that the nasal mucosa would not reach medially to be placed together.  at this point, the decision was made to proceed with vomer flaps.  the flaps are __________ infiltrated the vomer with the help of lidocaine with epinephrine after an incision in the manner of an open book.  the incision was done with a 15c blade.  the vomer flaps were dissected, and the mucosa was moved laterally to approximate to the nasal mucosa of the hard palate.  this was approximated on both sides with 5-0 chromic running and interrupted stitches, and i proceeded to the remaining of the posterior aspect of the nasal mucosa with a 5-0 chromic and a 4-0 chromic.  then 2 stitches of 4-0 vicryl were applied to the soft palate in the delaire manner through the full thickness of the mucosa and muscle on one side, on the other side, and then coming back on the mucosa to evert the edges of the soft palate.  the remaining part of the soft palate was placed together with 4-0 vicryl and 4-0 chromic interrupted stitches.  the throat pack was removed.  the palate was cleaned.  the dingman retractor was removed, and a single stitch after infiltration of lidocaine without epinephrine at the level of the midline of the tongue was applied with 2-0 silk to the dorsal aspect of the tongue and attached to the right cheek with a piece of tegaderm.  the patient tolerated the procedure without complications.  bss is applied to the eye after removing the tegaderm.  i was present and participated in all aspects of the procedure.  the sponge, needle, and instrument count were completed at the end of the procedure.  the patient tolerated the procedure without complications and was transferred to the recovery room in a stable condition.",11
"preoperative diagnosis:,1.  acute bowel obstruction.,2.  umbilical hernia.,postoperative diagnosis:,1.  acute small bowel obstruction.,2.  incarcerated umbilical hernia.,procedure performed:,1.  exploratory laparotomy.,2.  release of small bowel obstruction.,3.  repair of periumbilical hernia.,anesthesia: , general with endotracheal intubation.,complications:,  none.,disposition: , the patient tolerated the procedure well and was transferred to recovery in stable condition.,specimen: , hernia sac.,history:  ,the patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,intraoperative findings: , the patient was found to have an incarcerated umbilical hernia.  there was a loop of small bowel incarcerated within the hernia sac.  it showed signs of ecchymosis, however no signs of any ischemia or necrosis.  it was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,procedure: , after informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  the patient was brought to the operating suite.  after general endotracheal intubation, prepped and draped in normal sterile fashion.  a midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  dissection was then carried down to the fascia.  using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  the abdomen was entered under direct visualization.  the small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  the remaining of the fascia was then extended using metzenbaum scissors.  the hernia sac was removed using mayo scissors and sent off as specimen.  next, the bowel was run from the ligament of treitz to the ileocecal valve with no evidence of any other abnormalities.  the small bowel was then milked down removing all the fluid.  the bowel was decompressed distal to the obstruction.  once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 vicryl suture in the figure-of-eight fashion the fascia was closed.  the umbilicus was then reapproximated to its anatomical position with a #1 vicryl suture.  a #3-0 vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  sterile dressings were applied.  the patient tolerated the procedure well and was transferred to recovery in stable condition.",14
"history: , a 34-year-old male presents today self-referred at the recommendation of emergency room physicians and his nephrologist to pursue further allergy evaluation and treatment.  please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at abc medical center for further details and studies.  in summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from abc medical center to xyz medical center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to keflex, which was being used to treat a skin cellulitis dialysis shunt infection.  in summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions.  he currently is not taking any medication for allergies.  he is taking atenolol for blood pressure control.  no further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,past medical history:,  history of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,past surgical history:,  permcath insertion times 3 and peritoneal dialysis.,family history: , strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,current medications: , atenolol, sodium bicarbonate, lovaza, and dialyvite.,allergies: , heparin causing thrombocytopenia.,social history: , denies tobacco or alcohol use.,physical examination:  ,vital signs:  age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,general:  the patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,head:  normocephalic.  no masses or lesions noted.,face:  no facial tenderness or asymmetry noted.,eyes:  pupils are equal, round and reactive to light and accommodation bilaterally.  extraocular movements are intact bilaterally.,ears:  the tympanic membranes are intact bilaterally with a good light reflex.  the external auditory canals are clear with no lesions or masses noted.  weber and rinne tests are within normal limits.,nose:  the nasal cavities are patent bilaterally.  the nasal septum is midline.  there are no nasal discharges.  no masses or lesions noted.,throat:  the oral mucosa appears healthy.  dental hygiene is maintained well.  no oropharyngeal masses or lesions noted.  no postnasal drip noted.,neck:  the neck is supple with no adenopathy or masses palpated.  the trachea is midline.  the thyroid gland is of normal size with no nodules.,neurologic:  facial nerve is intact bilaterally.  the remaining cranial nerves are intact without focal deficit.,lungs:  clear to auscultation bilaterally.  no wheeze noted.,heart:  regular rate and rhythm.  no murmur noted.,impression:  ,1.  acute allergic reaction, etiology uncertain, however, suspicious for keflex.,2.  renal failure requiring dialysis.,3.  hypertension.,recommendations:  ,rast allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow.  if there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions.  at this point, i would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and i would consider this an allergy.  being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but i do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions.  an epipen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an epipen.",5
"cc:, episodic mental status change and rue numbness, and chorea (found on exam).,hx:, this 78y/o rhm was referred for an episode of unusual behavior and rue numbness. in 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. evaluation at that time revealed an serum glucose of >500mg/dl and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. his wife had taken over the family finances.,he had also been ""stumbling,"" when ambulating, for 2 months prior to presentation. he was noted to be occasionally confused upon awakening for last several months. on 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. there had been no change in sleep, appetite, or complaint of depression.,in addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of rue numbness. there was no face or lower extremity involvement.,during the last year he had developed unusual movements of his extremities.,meds:, nph humulin 12u qam and 6u qpm. advil prn.,pmh:, 1) traumatic amputation of the 4th and 5th digits of his left hand.  2) hospitalized for an unknown ""nervous"" condition in the 1940's.,shx/fhx:, retired small engine mechanic who worked in a poorly ventilated shop. married with 13 children. no history of etoh, tobacco or illicit drug use. father had tremors following a stroke. brother died of brain aneurysm. no history of depression, suicide, or huntington's disease in family.,ros:, no history of cad, renal or liver disease, sob, chest pain, fevers, chills, night sweats or weight loss. no report of sign of bleeding.,exam:, bp138/63 hr65 rr15 36.1c,ms: alert and oriented to self, season; but not date, year, or place. latent verbal responses and direction following. intact naming, but able to repeat only simple but not complex phrases. slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. knew the last 3 presidents. 14/27 on mmse: unable to spell ""world"" backwards. unable to read/write for complaint of inability to see without glasses.,cn: ii-xii appeared grossly intact. eom were full and smooth and without unusual saccadic pursuits. okn intact. choreiform movements of the tongue were noted.,motor: 5/5 strength throughout with guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. no motor impersistence noted.,sensory: unreliable.,cord: ""normal"" fnf, hks, and ram, bilaterally.,station: no romberg sign.,gait: unsteady and wide-based.,reflexes: bue 2/2, patellar 2/2, ankles trace/trace, plantars were flexor bilaterally.,gen exam: 2/6 systolic ejection murmur in aortic area.,course:, no family history of huntington's disease could be elicited from relatives. brain ct, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. carotid duplex, 1/18/93: rica 0-15%, lica 16-49% stenosis and normal vertebral artery flow bilaterally. transthoracic echocardiogram (tte),1/18/93: revealed severe aortic fibrosis or valvular calcification with ""severe"" aortic stenosis in the face of ""normal"" lv function. cardiology felt the patient the patient had asymptomatic aortic stenosis. eeg, 1/20/93, showed low voltage delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. mri brain, 1/22/93: multiple focal and more confluent areas of increased t2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased t2 signal and decreased t1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. there were no masses or areas of abnormal enhancement. tsh, ft4, vit b12, vdrl, urine drug and heavy metal screens were unremarkable. csf,1/19/93: glucose 102 (serum glucose 162mg/dl), protein 45mg/dl, rbc o, wbc o, cultures negative. spep negative. however serum and csf beta2 microglobulin levels were elevated at 2.5 and 3.1mg/l, respectively. hematology felt these may have been false positives. cbc, 1/17/93: hgb 10.4g/dl (low), hct 31% (low), rbc 3/34mil/mm3 (low), wbc 5.8k/mm3, plt 201k/mm3. retic 30/1k/mm3 (normal). serum iron 35mcg/dl (low), tibc 201mcg/dl (low), fesat 17% (low), crp 0.1mg/dl (normal), esr 83mm/hr (high). bone marrow bx: normal with adequate iron stores. hematology felt the finding were compatible with anemia of chronic disease. neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. the pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. the patient was discharged1/22/93 on asa 325mg qd. he was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.",32
"history:,  a is here for a follow up appointment at our pediatric rheumatology clinic as well as the ccs clinic.  a is a 17-year-old male with oligoarticular arthritis of his right knee.  he had a joint injection back in 03/2007 and since then he has been doing relatively well.  he is taking indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  he denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  denies any fevers or any rashes.,physical examination:,  on physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  he is alert, active, and oriented in no distress.  he has no facial rashes, no lymphadenopathy, no alopecia.  funduscopic examination is within normal limit.  he has no cataracts and symmetric pupils to light and accommodation.  his chest is clear to auscultation.  the heart has a regular rhythm with no murmur.  the abdomen is soft and nontender with no :  visceromegaly.  musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  lower extremities:  he still has some weakness of the knees, hip areas, and the calf muscles.  he does have minus/plus swelling of the right knee with a very hypermobile patella.  there is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,in terms of his laboratories, they were not done today.,assessment: , this is a 17-year-old male with oligoarticular arthritis.  he is hla-b27 negative.,plan:,  in terms of the plan, i discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  i am going to switch him to indocin 75 mg sr just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an mri.  we will see him back in three months.  he was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  future plans for a may include physical therapy and more stronger medications as well as imaging studies with an mri.  today he received his flu shot.  discussed this with a and his aunt and they had no further questions.",5
"title of operation: , austin bunionectomy with internal screw fixation, first metatarsal, left foot.,preoperative diagnosis:,  bunion deformity, left foot.,postoperative diagnosis: , bunion deformity, left foot.,anesthesia: , monitored anesthesia care with 15 ml of 1:1 mixture of 0.5% marcaine and 1% lidocaine plain.,hemostasis: , 45 minutes, left ankle tourniquet set at 250 mmhg.,estimated blood loss:,  less than 10 ml.,materials used: , 2-0 vicryl, 3-0 vicryl, 4-0 vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the osteomed screw fixation system.,description of the procedure:,  the patient was brought to the operating room and placed on the operating table in a supine position.  after adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  the left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmhg.  the left foot was then prepped, scrubbed, and draped in normal sterile technique.  the left ankle tourniquet was inflated.  attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  the incision was deepened through subcutaneous tissues.  all the bleeders were identified, cut, clamped, and cauterized.  the incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  all the tendinous neurovascular structures were identified and retracted from the site to be preserved.  using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  the conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  a lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  the dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  the same saw was used to perform an austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  the dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  the capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  the same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 osteomed system upon insertion of the screws, which was accomplished using ao technique.  the wires were removed.  fixation on the table was found to be excellent.  reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  the remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  the area was copiously flushed with saline.  the periosteal and capsular tissues were approximated with 2-0 and 3-0 vicryl suture material, 4-0 vicryl was used to approximate the subcutaneous tissues.  the incision site was reinforced with steri-strips.  at this time, the patient's left ankle tourniquet was deflated.  the time was 45 minutes.  immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  the patient's incision was covered with xeroform, copious amounts of fluff and kling, stockinette, and an ace bandage.  the patient's left foot was then placed in a surgical shoe.  the patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  the patient was given pain medication and instructions on how to control her postoperative course.  the patient was discharged from hospital according to nursing protocol and was advised to follow up with dr. x in one week's time for her first postoperative appointment.",37
"preoperative diagnosis:,  phimosis.,postoperative diagnoses:,  phimosis.,operations:,  circumcision.,anesthesia: , lma.,ebl:,  minimal.,fluids: , crystalloid.,brief history: , this is a 3-year-old male, who was referred to us from dr. x's office with phimosis.  the patient had spraying of urine and ballooning of the foreskin with voiding.  the urine seemed to have collected underneath the foreskin and then would slowly drip out.  options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  the patient's family understood all the complications and wanted to proceed with the procedure.  consent was obtained using interpreter.,description of procedure:  ,the patient was brought to the or and anesthesia was applied.  the patient was placed in supine position.  the patient was prepped and draped in usual sterile fashion.  all the penile adhesions were released prior to the prepping.  the extra foreskin was marked off, 1 x 3 gamco clamp was used.  hemostasis was obtained after removing the extra foreskin using the gamco clamp.,using 5-0 monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  there was excellent hemostasis.  dermabond was applied.  the patient was brought to recovery at the end of the procedure in stable condition.",37
"reason for consultation: , mesothelioma.,history of present illness: , the patient is a 73-year-old pleasant caucasian male who is known to me from his previous hospitalization.  he has also been seen by me in the clinic in the last few weeks.  he was admitted on january 18, 2008, with recurrent malignant pleural effusion.  on the same day, he underwent vats and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by dr. x.  he was found to have 2.5l of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  his hospital course here has been significant for dyspnea, requiring icu stay.  he also had a chest tube, which was taken out few days ago.  he has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  the biopsy from the pleural nodule done on the right on january 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  immunohistochemical staining showed tumor cells positive for calretinin and focally positive for d2-40, moc-31.  tumor cells are negative for cdx-2, and monoclonal cea.,the patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  he does have edema in his lower extremities.  he is currently on 4l of oxygen.  he denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  no neurological or musculoskeletal signs or symptoms.  he reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  he denies any other complaints.,past medical history:,  left ventricular systolic dysfunction as per the previous echocardiogram done in december 2007, history of pneumonia in december 2007, admitted to xyz hospital.  history of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in xyz hospital.,allergies:,  no known drug allergies.,current medications:  ,in the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, zosyn, p.r.n. acetaminophen, and hydrocodone.,social history: , the patient is married and lives with his spouse.  he has history of tobacco smoking and also reports history of alcohol abuse.  no history of illicit drug abuse.,family history:  ,significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,review of systems: , as stated above.  he denies any obvious asbestos exposure, as far as he can remember.,physical examination,general:  he is awake, alert, in no acute distress.  he is currently on 4l of oxygen by nasal cannula.,vital signs:  blood pressure 97/65 mmhg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees fahrenheit.,heent:  no icterus or sinus tenderness.  oral mucosa is moist.,neck:  supple.  no lymphadenopathy.,lungs:  clear to auscultation except few diffuse wheezing present bilaterally.,cardiovascular:  s1 and s2 normal.,abdomen:  soft, nondistended, and nontender.  no hepatosplenomegaly.  bowel sounds are present in all four quadrants.,extremities:  bilateral pedal edema is present in both the extremities.  no signs of dvt.,neurological:  grossly nonfocal.,investigation:,  labs done on january 28, 2008, showed bun of 23 and creatinine of 0.9.  liver enzymes checked on january 17, 2008, were unremarkable.  cbc done on january 26, 2008, showed wbc of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  chest x-ray from yesterday shows right-sided port-a-cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,assessment,1.  mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  chronic obstructive pulmonary disease.,3.  paroxysmal atrial fibrillation.,4.  malignant pleural effusion, status post surgery as stated above.,5.  anemia of chronic disease.,recommendations,1.  compare the slides from the previous biopsy done in december at xyz hospital with recurrent pleural nodule biopsy slides.  i have discussed regarding this with dr. y in pathology here at methodist xyz hospital.  i will try to obtain the slides for comparison from xyz hospital for comparison and immunohistochemical staining.,2.  i will also discuss with dr. x and also with intervention radiologist at xyz hospital regarding the exact sites of the two biopsies.,3.  once the results of the above are available, i will make further recommendations regarding treatment.  the patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to triumph hospital for rehab, which i agree with.,4.  continue present care.,discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  they clearly understand the above.  they also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.",3
"reason for consultation:, regarding weakness and a history of polymyositis.,history of present illness:, the patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. the patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. she was previously followed by dr. c, neurology, over several years but was last followed up in the last three to four years. she is also seeing dr. r at rheumatology in the past. initially, she was treated with steroids but apparently was intolerant of that. she was given other therapy but she is unclear of the details of that. she has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. she has also had a history of spine disease though the process there is not known to me at this time.,she presented on february 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. she reports that strength in the proximal upper extremities has remained good. however, she has no grip strength. apparently, this has been progressive over the last several years as well. she also presently has virtually no strength in the lower extremities and that is worse within the last few days. prior to admission, she has had cough with mild shortness of breath. phlegm has been dark in color. she has had reflux and occasional dysphagia. she has also had constipation but no other gi issues. she has no history of seizure or stroke like symptoms. she occasionally has headaches. no vision changes. other than the left flank skin changes, she has had no other skin issues. she does have a history of dvt but this was 30 to 40 years ago. no history of dry eyes or dry mouth. she denies chest pain at present.,past medical and surgical history:, hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of dvt, previous colonoscopy that was normal, renal artery stenosis.,medications:, medications prior to admission: os-cal, zyrtec, potassium, plavix, bumex, diovan.,current medications:, acyclovir, azithromycin, ceftriaxone, diovan, albuterol, robitussin, hydralazine, atrovent.,allergies:, no known drug allergies.,social history:, she is a widow. she has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. she also has a son with lumbar spine disease. no tobacco, alcohol or iv drug abuse.,family history:, no history of neurologic or rheumatologic issues.,review of systems:, as above.,physical examination:,vital signs: she is afebrile. current temperature 98. respirations 16, heart rate 80 to 90. blood pressure 114/55.,general appearance: she is alert and oriented and in no acute distress. she is pleasant. she is reclining in the bed.,heent: pupils are reactive. sclera are clear. oropharynx is clear.,neck: no thyromegaly. no lymphadenopathy.,cardiovascular: heart is regular rate and rhythm.,respiratory: lungs have a few rales only.,abdomen: positive bowel sounds. soft, nontender, nondistended. no hepatosplenomegaly.,extremities: no edema.,skin: left flank dermatome with vesicular rash that is red and raised consistent with zoster.,joints: no synovitis anywhere. strength is 5/5 in the proximal upper extremities. proximal lower extremities are 0 out of 5. she has no grip strength at present.,neurological: cranial nerves ii through xii grossly intact. reflexes 2/4 at the biceps, brachial radialis, triceps. nil out of four at the patella and achilles bilaterally. sensation seems normal. chest x-ray shows copd, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,laboratory data:, white blood cell count 6.1, hemoglobin 11.9, platelets 314,000. sed rate 29 and 30. electrolytes: sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. tsh is slightly elevated at 5.38. cpk 36, bnp 645. troponin less than 0.04.,impression:,1. the patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. she has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. this in the setting of an acute illness, presumably a pneumonic process.,2. she also gives a history of spine disease though the details of that process are not available either.,the question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. zoster of the left flank.,4. left lower lobe pneumonic process.,5. elevation of the thyroid stimulating hormone.,recommendations:,1. i have asked dr. c to see the patient and he has done so tonight. he is planning for emg nerve conduction study in the morning.,2. i would consider further spine evaluation pending review of the emg nerve conduction study.,3. agree with supportive care being administered thus far and will follow along with you.",5
"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.",12
"chief complaint:,  detox from heroin.,history of present illness: , this is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  the patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,past medical history: , remarkable for chronic pain.  he has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  he has previously been followed by abc but has not seen him for several years.,review of systems:  ,the patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  denies any headache or visual complaints.  no hallucinations.  no chest pain, shortness of breath, abdominal pain or back pain.  denies any abscesses.,social history: , the patient is a smoker.  admits to heroin use, alcohol abuse as well.  also admits today using cocaine.,family history:,  noncontributory.,medications: , he has previously been on analgesics and pain medications chronically.  apparently, he just recently got out of prison.  he has previously also been on klonopin and lithium.  he was previously on codeine for this pain.,allergies: , none.,physical examination: , vital signs:  the patient is afebrile.  he is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  his respiratory rate is normal at 18.  general:  the patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  heent:  unremarkable.  pupils are actually moderately dilated about 4 to 5 mm, but reactive.  extraoculars are intact.  his oropharynx is clear.  neck:  supple.  his trachea is midline.  lungs:  clear.  he has good breath sounds and no wheezing.  no rales or rhonchi.  good air movement and no cough.  cardiac:  without murmur.  abdomen:  soft and nontender.  he has multiple track marks, multiple tattoos, but no abscesses.  neurologic:  nonfocal.,impression: , medical examination for the patient who will be detoxing from heroin.,assessment and plan:  ,at this time, i think the patient can be followed up at xyz.  i have written a prescription of clonidine and phenergan for symptomatic relief and this has been faxed to the pharmacy.  i do not think he needs any further workup at this time.  he is discharged otherwise in stable condition.",5
"preoperative diagnosis:  ,pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,postoperative diagnosis: , pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,procedure: , primary low segment cesarean section.  the patient was placed in the supine position under spinal anesthesia with a foley catheter in place and she was prepped and draped in the usual manner.  a low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  bleeding points were snapped and coagulated along the way.  the fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  these were divided in the midline revealing the peritoneum, which was opened vertically.  the uterus was in mid position.  the bladder flap was incised elliptically and reflected caudad.  a low transverse hysterotomy incision was then constructed and extended bluntly.  amniotomy revealed clear amniotic fluid.  a live born vigorous male infant was then delivered from the right occiput transverse position.  the infant breathed and cried spontaneously.  the nares and pharynx were suctioned.  the umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  cord blood samples were obtained.  the placenta was manually removed and the uterus was eventrated for closure.  the edges of the uterine incision were grasped with pennington clamps and closure was carried out in standard two-layer technique using 0 vicryl suture with the second layer imbricating the first.  hemostasis was completed with an additional figure-of-eight suture of 0 vicryl.  the cornual sac and gutters were irrigated.  the uterus was returned to the abdominal cavity.  the adnexa were inspected and were normal.  the abdomen was then closed in layers.  fascia was closed with running 0 vicryl sutures, subcutaneous tissue with running 3-0 plain catgut, and skin with 3-0 monocryl subcuticular suture and steri-strips.  blood loss was estimated at 700 ml.  all counts were correct.,the patient tolerated the procedure well and left the operating room in excellent condition.",37
"preoperative diagnoses,1.  cervical radiculopathy, c5-c6 and c6-c7.,2.  symptomatic cervical spondylosis, c5-c6 and c6-c7.,3.  symptomatic cervical stenosis, c5-c6 and c6-c7.,4.  symptomatic cervical disc herniations, c5-c6 and c6-c7.,postoperative diagnoses,1.  cervical radiculopathy, c5-c6 and c6-c7.,2.  symptomatic cervical spondylosis, c5-c6 and c6-c7.,3.  symptomatic cervical stenosis, c5-c6 and c6-c7.,4.  symptomatic cervical disc herniations, c5-c6 and c6-c7.,operative procedure,1.  cpt code 63075:  anterior cervical discectomy and osteophytectomy, c5-c6.,2.  cpt code 63076:  anterior cervical discectomy and osteophytectomy, c6-c7, additional level.,3.  cpt code 22851:  application of prosthetic interbody fusion device, c5-c6.,4.  cpt code 22851-59:  application of prosthetic interbody fusion device, c6-c7, additional level.,5.  cpt code 22554-51:  anterior cervical interbody arthrodesis, c5-c6.,6.  cpt code 22585:  anterior cervical interbody arthrodesis, c6-c7, additional level.,7.  cpt code 22845:  anterior cervical instrumentation, c5-c7.,anesthesia:,  general endotracheal.,estimated blood loss:  ,negligible.,drains: , small suction drain in the cervical wound.,complications:,  none.,procedure in detail:,  the patient was given intravenous antibiotic prophylaxis and thigh-high ted hoses were placed on the lower extremities while in the preanesthesia holding area.  the patient was transported to the operative suite and on to the operative table in the supine position.  general endotracheal anesthesia was induced.  the head was placed on a well-padded head holder.  the eyes and face were protected from pressure.  a well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  the arms were tucked and draped to the sides.  all bony prominences were well padded.  an x-ray was taken to confirm the correct level of the skin incision.  the anterior neck was then prepped and draped in the usual sterile fashion.,a straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  the superficial and deep layers of the deep cervical fascia were divided.  the midline structures were reflected to the right side.  care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  the carotid sheath was palpated and protected laterally.  an x-ray was taken to confirm the level of c5-c6 and c6-c7.,the longus colli muscle was dissected free bilaterally from c5 to c7 using blunt dissection.  hemostasis was obtained using the electrocautery.  the blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  at c5-c6, the anterior longitudinal ligament was divided transversely.  straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  all cartilages were scraped off the inferior endplate of c5 and from the superior endplate of c6.  the disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  the posterior longitudinal ligament was resected using a 1 mm kerrison rongeur.  beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm kerrison rongeurs.  the patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  a portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  both nerve roots were visualized and noted to be free of encroachment.  the same procedure was then carried out at c6-c7 with similar findings.  the only difference in the findings was that at c6-c7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,in preparation for the arthrodesis, the endplates of c5, c6, and c7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  the disc spaces were then measured to the nearest millimeter.  attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  the grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  the grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  the grafts were impacted into the disc spaces.  there was complete bony apposition between the ends of the bone grafts and the vertebral bodies of c5, c6, and c7.  a blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  an appropriate length synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  the plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at c6.  screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  the plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,an x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,blood loss was minimal.  the wound was irrigated with irrigant solution containing antibiotics.  the wound was inspected and judged to be dry.  the wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 vicryl running suture, the subdermal and subcuticular layers with #4-0 monocryl interrupted sutures, and the skin with steri-strips.  the sponge and needle count were correct.  a sterile dressing was applied to the wound.  the neck was placed in a cervical orthosis.  the patient tolerated the procedure and was transferred to the recovery room in stable condition.",37
"discharge summary,summary of treatment planning:,two major problems were identified at the admission of this adolescent:,1.",31
"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.",15
"preoperative diagnosis: , breast assymetry, status post previous breast surgery.,postoperative diagnosis:  ,breast assymetry, status post previous breast surgery.,operation: , capsulotomy left breast, flat advancement v to y left breast for correction lower pole defect.,anesthesia:,  lma.,findings and procedure:  ,the patient is a 35-year-old female who presents status post multiple breast surgeries with resultant flatness of the lower pole of the left breast.  the nipple inframammary fold distance is approximately 1.5 cm shorter than the fuller right breast.  the patient has bilateral mentor-smooth round moderate projection jell-filled mammary prosthesis, 225 cc.,the patient was marked in the upright position for mobilization of lateral skin flaps and increase in the length of the nipple inframammary fold distance.  she was then brought to the operating room and after satisfactory lma anesthesia had been induced, the patient was prepped and draped in the usual manger.  the patient received a gram of kefzol prior to beginning the procedure.  the previous inverted t-scar was excised down to the underlying capsule of the breast implant.  the breast was carefully dissected off of the underlying capsule.  care being taken to preserve the vascular supply to the skin and breast flap.  when the anterior portion of the breast was dissected free of the underlying capsule, the posterior aspect of the capsule was then dissected off of the underlying pectoralis muscle.  a posterior incision was made on the backside of the capsule at the proximate middle portion of the capsule and then reflected inferiorly thereby creating a superior based capsular flap.  the lateral aspects of the capsule were then opened and the inferior edge of the capsule was then sutured to the underside of the inframammary flap with 2-0 monocryl statures.  care was taken to avoid as much exposure of the implant, as well as damage to the implant.  when the flap had been created and advanced, hemostasis was obtained and the area copiously irrigated with a solution of bacitracin 50,000 units, kefzol 1 g, gentamicin 80 mg, and 500 cc of saline.  the lateral skin both medially and laterally were then completely freed and the vertical incision of the inverted t was then extended the 2 cm and sutured with a trifurcation suture of 2-0 biosyn.  this lengthened the vertical portion of the mastopexy scar to allow for descent of the implant and roundness of the inferior pole of the left breast.  the remainder of the inverted t was closed with interrupted sutures of 3 and 2-0 biosyn and the skin was closed with continuous suture of 5-0 nylon.  bacitracin and a standard breast dressing were applied.,the anesthesia was terminated and the patient was recovered in the operating room.  sponge, instrument, needle count reported as corrected.  estimated blood loss negligible.",6
"chief complaint: , this is a previously healthy 45-year-old gentleman.  for the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  on the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where dr. xyz noted an incarcerated umbilical hernia.  he was able to reduce this, with relief of pain.  he is now being admitted for definitive repair.,past medical history: , significant only for hemorrhoidectomy.  he does have a history of depression and hypertension.,medications: , his only medications are ziac and remeron.,allergies:,  no allergies.,family history: , negative for cancer.,social history:,  he is single.  he has 2 children.  he drinks 4-8 beers per night and smokes half a pack per day for 30 years.  he was born in salt lake city.  he works in an electronic assembly for harmony music.  he has no history of hepatitis or blood transfusions.,physical examination:,general:  examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,heent:  no scleral icterus.,neck:  no cervical, supraclavicular, or axillary adenopathy.,lungs:  clear.,heart:  regular.  no murmurs or gallops.,abdomen:  as noted, obese with mildly visible bulging in the umbilicus at the superior position.  with gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,diagnostic studies:  ,normal sinus rhythm on ekg, prolonged qt.  chest x-ray was negative.  the abdominal x-rays were read as being negative.  his electrolytes were normal.  creatinine was 0.9.  white count was 6.5, hematocrit was 48, and platelet count was 307.,assessment and plan:,  otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.",5
"exam: , ct scan of the abdomen and pelvis without and with intravenous contrast.,clinical indication: , left lower quadrant abdominal pain.,comparison: , none.,findings: , ct scan of the abdomen and pelvis was performed without and with intravenous contrast.  total of 100 ml of isovue was administered intravenously.  oral contrast was also administered.,the lung bases are clear.  the liver is enlarged and decreased in attenuation.  there are no focal liver masses.,there is no intra or extrahepatic ductal dilatation.,the gallbladder is slightly distended.,the adrenal glands, pancreas, spleen, and left kidney are normal.,a 12-mm simple cyst is present in the inferior pole of the right kidney.  there is no hydronephrosis or hydroureter.,the appendix is normal.,there are multiple diverticula in the rectosigmoid.  there is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  these findings are consistent with diverticulitis.  no pneumoperitoneum is identified.  there is no ascites or focal fluid collection.,the aorta is normal in contour and caliber.,there is no adenopathy.,degenerative changes are present in the lumbar spine.,impression: , findings consistent with diverticulitis.  please see report above.",14
"preoperative diagnoses: , epiretinal membrane, right eye.  cme, right eye.,postoperative diagnoses: , epiretinal membrane, right eye.  cme, right eye.,procedures: , pars plana vitrectomy, membrane peel, 23-gauge, right eye.,preoperative findings:,  the patient had epiretinal membrane causing cystoid macular edema.  options were discussed with the patient stressing that the visual outcome was guarded.  especially since this membrane was of chronic duration there is no guarantee of visual outcome.,description of procedure: , the patient was wheeled to the or table.  local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of xylocaine and marcaine was delivered to retrobulbar area and massaged and verified.  preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  the fluid was run.  then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ilm forceps, the membrane was peeled off in its entirety.  there were no complications.  dvt precautions were in place.  i, as attending, was present in the entire case.",37
"preoperative diagnosis: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,postoperative diagnoses: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,operative procedures,1.  anterior cervical discectomy with decompression, c3-4.,2.  arthrodesis with anterior interbody fusion, c3-4.,3.  spinal instrumentation using pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  implant using peek 7 mm.,5.  allograft using vitoss.,drains: , round french 10 jp drain.,fluids: , 1800 ml of crystalloids.,urine output:  ,1000 ml.,specimens: , none.,complications:  ,none.,anesthesia: , general endotracheal anesthesia.,estimated blood loss:  ,less than 100 ml.,condition:  ,to postanesthesia care unit extubated with stable vital signs.,indications for the operation:  ,this is a case of a very pleasant 32-year-old caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  about two days ago, he started noticing weakness on the left arm.  the patient also noted shuffling gait.  the patient presented to a family physician and was referred to dr. x for further evaluation.  dr. x could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an mri of the brain was essentially unremarkable as well as mri of the thoracic spine.  mri of the cervical spine, however, revealed an acute disk herniation at c3-c4 with evidence of stenosis and cord changes.  based on these findings, i recommended decompression.  the patient was started on decadron at 10 mg iv q.6h.  operation, expected outcome, risks, and benefits were discussed with him.  risks to include but not exclusive of bleeding and infection.  bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  the hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  there is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  there is also the possibility of infection, which can be superficial and treated with iv and p.o. antibiotics.  however, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  this may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  there is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  this too can compromise airway and may require return to the operating room for repair of the dural tear.  there is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  the patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  the patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,description of procedure:  ,the patient was brought to the operating room, awake, alert and not in any form of distress.  after smooth induction and intubation, a foley catheter was inserted.  no monitoring leads were placed.  the patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  localizing x-ray verified the marker to be right at the c3-4 interspace.  proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  the area was then prepped with duraprep.,after sterile drapes were laid out, an incision was made using a scalpel blade #10.  wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  the anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  the prevertebral fascia was identified.  localizing x-ray verified another marker to be at the c3-4 interspace.  proceeded to strip the longus colli muscles off the vertebral body of c3 and c4 and a self-retaining retractor was then laid out.  there was some degree of anterior osteophyte and this was carefully drilled down with a midas 5-mm bur.  the disk was then cut through the annulus and removal of the disk was done with the use of the midas 5-mm bur and later a 3-mm bur.  the inferior endplate of c3 and the superior endplate of c4 were likewise drilled out together with posterior inferior osteophyte at the c3 and the posterior superior osteophyte at c4.  there was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  by careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of gelfoam on the patient's left because of profuse venous bleeder.  with this completed, the valsalva maneuver showed no evidence of any csf leakage.  a 7-mm implant with its interior packed with vitoss was then tapped into place.  an 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  the area was irrigated with saline, with bacitracin solution.  postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  a round french 10 jp drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures for the platysma, vicryl 4-0 subcuticular stitch for the dermis and dermabond.  the catheter was anchored to the skin with a nylon 3-0 stitch.  dressing was placed only on the exit site of the drain.  c-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.",22
"subjective:,  the patient is well-known to me.  he comes in today for a comprehensive evaluation.  really, again he borders on health crises with high blood pressure, diabetes, and obesity.  he states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  he knows better and has been through some diabetes training.  in fact, interestingly enough, with his current medications which include the lantus at 30 units along with actos, glyburide, and metformin, he achieved ideal blood sugar control back in august 2004.  since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  he has had elevated blood pressure.  his other concerns include allergic symptoms.  he has had irritable bowel syndrome with some cramping.  he has had some rectal bleeding in recent days.  also once he wakes up he has significant difficulty in getting back to sleep.  he has had no rectal pain, just the bleeding associated with that.,medications/allergies:,  as above.,past medical/surgical history: , reviewed and updated - see health summary form for details.,family and social history:,  reviewed and updated - see health summary form for details.,review of systems:,  constitutional, eyes, ent/mouth, cardiovascular, respiratory, gi, gu, musculoskeletal, skin/breasts, neurologic, psychiatric, endocrine, heme/lymph, allergies/immune all negative with the following exceptions:  none.,physical examination:,vital signs:  as above.,general:  the patient is alert, oriented, well-developed, obese male who is in no acute distress.,heent:  perrla.  eomi.  tms clear bilaterally.  nose and throat clear.,neck:  supple without adenopathy or thyromegaly.  carotid pulses palpably normal without bruit.,chest:  no chest wall tenderness or breast enlargement.,heart:  regular rate and rhythm without murmur, clicks, or rubs.,lungs:  clear to auscultation and percussion.,abdomen:  significantly obese without any discernible organomegaly.  gu:  normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,rectal:  smooth, nonenlarged prostate with just some irritation around the rectum itself.  no hemorrhoids are noted.,extremities:  some slow healing over the tibia.  without clubbing, cyanosis, or edema.  peripheral pulses within normal limits.,neurologic:  cranial nerves ii-xii intact.  strength, sensation, coordination, and reflexes all within normal limits.,skin:  noted to be normal.  no subcutaneous masses noted.,lymph system:  no lymphadenopathy noted.,back:  he has pain in his back in general.,assessment/plan:,1.  diabetes and hypertension, both under less than appropriate control.  in fact, we discussed increasing the lantus.  he appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  he knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  he will also check a hemoglobin a1c, lipid profile, urine for microalbuminuria and a chem profile.  i will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  he has allergic rhinitis for which zyrtec can be used.,2.  he has irritable bowel syndrome.  we will use metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  for the bleeding i would like to obtain a sigmoidoscopy.  it is bright red blood.,3.  for his insomnia, i found there is very little in the way of medications that are going to fix that, however i have encouraged him in good sleep hygiene.  i will look forward to seeing him back in a month.  i will call him with the results of his lab.  his medications were made out.  we will use some elocon cream for his seborrheic dermatitis of the face.  zyrtec and flonase for his allergic rhinitis.",15
"exam: , ct scan of the abdomen and pelvis with contrast.,reason for exam: , abdominal pain.,comparison exam: , none.,technique: , multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of omnipaque iv.  in addition, oral readicat was given.  reformatted sagittal and coronal images were obtained.,discussion:,  there are numerous subcentimeter nodules seen within the lung bases.  the largest measures up to 6 mm.  no hiatal hernia is identified.  consider chest ct for further evaluation of the pulmonary nodules.  the liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  no dilated loops of bowel.  there are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  in addition, there is soft tissue stranding seen of the lower pelvis.  in addition, the uterus is not identified.  correlate with history of recent surgery.  there is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  the bladder is within normal limits for technique.,no acute bony abnormalities appreciated.  no suspicious osteoblastic or osteolytic lesions.,impression:,1.  postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  numerous subcentimeter nodules seen within the lung bases.  consider chest ct for further characterization.",20
"preoperative diagnosis: , postoperative hemorrhage.,postoperative diagnosis:,  postoperative hemorrhage.,surgical procedure:  ,examination under anesthesia with control of right parapharyngeal space hemorrhage.,anesthesia:  ,general endotracheal technique.,surgical findings: , right lower pole bleeder cauterized with electrocautery with good hemostasis.,indications for surgery: , the patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  however, in the pacu after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,description of surgery:  ,the patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  a crowe-davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  there was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  there was no other bleeding noted.  the patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  there was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  no other bleeding was noted and the patient was recovered from general anesthetic.  she was extubated and left the operating room in good condition to postoperative recovery room area.  prior to extubation the patient's tonsillar fossa were injected with a 6 ml of 0.25% marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.",11
"title of operation: , revision laminectomy l5-s1, discectomy l5-s1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with bmp.,indications for surgery:  ,please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  this list was inclusive, but not exclusive.  an informed consent was obtained after all patient's questions were answered.,preoperative diagnosis:  ,severe lumbar spondylosis l5-s1, collapsed disk space, hypermobility, and herniated disk posteriorly.,postoperative diagnosis: , severe lumbar spondylosis l5-s1, collapsed disk space, hypermobility, and herniated disk posteriorly.,anesthesia: , general anesthesia and endotracheal tube intubation.,disposition: , the patient to pacu with stable vital signs.,procedure in detail:  ,the patient was taken to the operating room.  after adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the jackson table.  lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  an incision was carried out from l4 to s1.  hemostasis was obtained with bipolar and bovie cauterization.  a weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of l4, l5, and sacrum.  at this time, laminectomy was carried out of l5-s1.  thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  at this time, the disk was entered with a #15 blade and bipolar.  the disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  we were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of bmp 8 mm graft from medtronic.  at this time, dr. x will dictate the posterolateral fusion, pedicle screw fixation to l4 to s1 with compression and will dictate the closure of the wound.  there were no complications.",37
"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.",37
"preoperative diagnosis: , squamous cell carcinoma, left nasal cavity.,postoperative diagnosis:,  squamous cell carcinoma, left nasal cavity.,operations performed:,1.  nasal endoscopy.,2.  partial rhinectomy.,anesthesia:,  general endotracheal.,indications: , this is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  he also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  he has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  he was evaluated by dr. a, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  the preoperative examination shows induration of the nasal tip without significant erythema.  there is focal tenderness just cephalad to the alar crease.  there is no lesion either externally or intranasally.,procedure and findings: , the patient was taken to the operating room and placed in supine position.  following induction of adequate general endotracheal anesthesia, the left nose was decongested with afrin.  he was prepped and draped in standard fashion.  the left nasal cavity was examined by anterior rhinoscopy.  the septum was midline.  there was slight asymmetry of the nares.  no lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by dr. a, the septum, the lateral nasal wall, and the floor.  the 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  no lesion was detectable.  a left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by dr. a.  the submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  a diagnosis of diffuse invasive squamous cell carcinoma was rendered.  an alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  the incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  the full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  additional soft tissue was then taken from all margins tagging them for the pathologist.  the inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  a joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  additional soft tissue was taken in these regions along the superior margin.  the frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  a 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  this was all submitted to pathology for routine permanent examination.  xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  the anesthetic was then discontinued as the patient was extubated and transferred to the pacu in good condition having tolerated the procedure well.  sponge and needle counts were correct.",37
"preoperative diagnosis: , biliary colic.",14
"cystoscopy & visual urethrotomy,operative note:,  the patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  a storz urethrotome sheath was inserted into the urethra under direct vision.  visualization revealed a stricture in the bulbous urethra.  this was intubated with a 0.038 teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  visualization revealed no other lesions in the bulbous or membranous urethra.  prostatic urethra was normal for age.  no foreign bodies, tumors or stones were seen within the bladder.  over the guidewire, a #16-french foley catheter with a hole cut in the tip with a cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 ml of sterile water.,he was sent to the recovery room in stable condition.",38
"preoperative diagnosis: ,  hematemesis in a patient with longstanding diabetes. ,postoperative diagnosis:  ,mallory-weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,procedure:  , the procedure, indications explained and he understood and agreed.  he was sedated with versed 3, demerol 25 and topical hurricane spray to the oropharynx.  a bite block was placed.  the pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision.  esophagus revealed distal ulcerations.  additionally, the patient had a mallory-weiss tear.  this was subjected to bicap cautery with good ablation.  the stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting.  there were no ulcerations or erosions in the stomach.  the duodenum was entered, which was unremarkable.  the instrument was then removed.  the patient tolerated the procedure well with no complications.,impression: , mallory-weiss tear, successful bicap cautery. ,we will keep the patient on proton pump inhibitors.  the patient will remain on antiemetics and be started on a clear liquid diet.",37
"preoperative diagnosis:,  right common, internal and external carotid artery stenosis.,postoperative diagnosis:,  right common, internal and external carotid artery stenosis.,operations,1.  right common carotid endarterectomy.,2.  right internal carotid endarterectomy.,3.  right external carotid endarterectomy.,4.  hemashield patch angioplasty of the right common, internal and external carotid arteries.,anesthesia:,  general endotracheal anesthesia.,urine output: , not recorded,operation 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.  next the right neck was prepped and draped in the standard surgical fashion.  a #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  dissection was carried down to the level of the carotid artery using bovie electrocautery and sharp dissection with metzenbaum scissors.  the common, internal and external carotid arteries were identified.  the facial vein was ligated with #3-0 silk.  the hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  after dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  next, an umbilical tape was passed around the common carotid artery.  a #0 silk suture was passed around the internal and external carotid arteries.  the hypoglossal nerve was identified and preserved.  an appropriate sized argyle shunt was chosen.  a hemashield patch was cut to the appropriate size.  next, vascular clamps were placed on the external carotid artery.  debakey pickups were used to control the internal carotid artery and common carotid artery.  a #11-blade scalpel was used to make an incision on the common carotid artery.  the arteriotomy was lengthened onto the internal carotid artery.  next, the argyle shunt was placed.  it was secured in place.  next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  an inversion technique was used on the external carotid artery.  the artery was irrigated and free debris was removed.  next, we sewed the hemashield patch onto the artery using #6-0 prolene in a running fashion.  prior to completion of our anastomosis, we removed our shunt.  we completed the anastomosis.  next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  there was no evidence of bleeding.  full-dose protamine was given.  the incision was closed with #0 vicryl, followed by #2-0 vicryl, followed by #4-0 pds in a running subcuticular fashion.  a sterile dressing was applied.",3
"procedure:,  the test was performed in an observed hospital laboratory.  the patient was monitored for eeg, eog, jaw and leg emg, thoracoabdominal impedance, oral/nasal thermistors, ekg, and oximetry.  the test was performed due to suspicion of sleep apnea and poor sleep quality with frequent awakenings.,the patient's height 6 feet, 1 inch and his weight 260 pounds.,details: , total sleep period 377 minutes, total sleep time 241 minutes, sleep onset 33 minutes, and sleep efficiency 64%.  stage i 9%, stage ii 59%, stage iii 23%, and rem stage 9%.  there were 306 apneas and hypopnea with apnea/hypopnea index 76.  out of them 109 apneas and 197 hypopneas.  there were 40 arousals with index 9.9.  mean oxygen saturation 91% with lowest oxygen saturation 70%.  a 19% of sleep time was spent with oxygen saturation less than 90% and 1% with less than 80%.  oxygen saturation during awake 95%.  the patient slept in supine left side and right side, no preferred body position identified for apneas.  average pulse 85 bpms with lowest 61 and highest 116 bpms.  no significant snoring throughout the study.  no significant leg jerk movement.,summary: , severe obstructive sleep apnea with apnea/hypopnea index 76 and respiratory disturbance index 9.9.  suggest weight loss, thyroid function evaluation, and cpap titration study.",35
"history: , patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  she had been previously diagnosed with hyperthyroidism.  upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  she had been experiencing palpitations and tachycardia.  she had no diaphoresis, no nausea, vomiting, or dyspnea.,she had a significant tsh of 0.004 and a free t4 of 19.3.  normal ranges for tsh and free t4 are 0.5-4.7 µiu/ml and 0.8-1.8 ng/dl, respectively.  her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  she gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  she complained of sweating, but has experienced no diarrhea and no change in appetite.  she was given isosorbide mononitrate and iv steroids in the er.,family history:,  diabetes, hypertension, father had a coronary artery bypass graph (cabg) at age 34.,social history:,  she had a baby five months ago.  she smokes a half pack a day.  she denies alcohol and drug use.,medications:,  citalopram 10mg once daily for depression; low dose tramadol prn pain.,physical examination: , temperature 98.4; pulse 123; respiratory rate 16; blood pressure 143/74.,heent:  she has exophthalmos and could not close her lids completely.,cardiovascular:  tachycardia.,neurologic:  she had mild hyperreflexiveness.,lab:,  all labs within normal limits with the exception of sodium 133, creatinine 0.2, tsh 0.004, free t4 19.3 ekg showed sinus tachycardia with a rate of 122.  urine pregnancy test was negative.,hospital course: , after admission, she was given propranolol at 40mg daily and continued on telemetry.  on the 2nd day of treatment, the patient still complained of chest pain.  ekg again showed tachycardia.  propranolol was increased from 40mg daily to 60mg twice daily., a i-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  the normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  endocrine consult recommended radioactive i-131 for treatment of graves disease.,two days later she received 15.5mci of i-131.  she was to return home after the iodine treatment.  she was instructed to avoid contact with her baby for the next week and to cease breast feeding.,assessment / plan:,1. treatment of hyperthyroidism.  patient underwent radioactive iodine 131 ablation therapy.,2. management of cardiac symptoms stemming from hyperthyroidism.  patient was discharged on propranolol 60mg, one tablet twice daily.,3. monitor patient for complications of i-131 therapy such as hypothyroidism.  she should return to endocrine clinic in six weeks to have thyroid function tests performed.  long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. prevention of pregnancy for one year post i-131 therapy.  patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. monitor ocular health.  patient was given methylcellulose ophthalmic, one drop in each eye daily.  she should follow up in 6 weeks with the ophthalmology clinic.,6. management of depression.  patient will be continued on citalopram 10 mg.",5
"chief complaint: , left knee pain and stiffness.,history of present illness: , the patient is a 57-year-old with severe bilateral knee djd, left greater than right, with significant pain and limitations because of both.  he is able to walk approximately a 1/2-mile a day but is limited because of his knees.  stairs are negotiated 1 at a time.  his problems with bilateral knee djd have been well documented.  he had arthroscopy in the 1991/199two time frame for both of these.  he has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  at this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  he does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  significant pain is handled by narcotic medication.  his attending physician is dr. x.,past medical history: , hypertension.,prior surgeries:,1.  inguinal hernia on the left.,2.  baker's cyst.,3.  colon cancer removal.,4.  bilateral knee scopes.,5.  right groin hernia.,6.  low back surgery for spinal stenosis.,7.  status post colon cancer second surgery.,medications:,1.  ambien 12.5 mg nightly.,2.  methadone 10 mg b.i.d.,3.  lisinopril 10 mg daily.,iv medications for pain:  ,demerol appears to work the best.,allergies: , levaquin and cipro cause rashes; ibuprofen causes his throat to swell, fortaz causes an unknown reaction.,review of systems:  ,he does have paresthesias down into his thighs secondary to spinal stenosis.,social history: , married.  he is retired, being a pepsi-cola driver secondary to his back and knees.,habits: , no tobacco or alcohol.  chewed until 2003.,recreational pursuits:  ,golfs, gardens, woodworks.,family history:,1.  cancer.,2.  coronary artery disease.,physical examination:,general appearance:  a pleasant, cooperative 57-year-old white male.,vital signs:  height 5' 9"", weight 167.  blood pressure 148/86.  pulse 78 per minute and regular.,heent:  unremarkable.  extraocular movements are full.  cranial nerves ii-xii intact.,neck:  supple.,chest:  clear.,cardiovascular:  regular rhythm.  normal s1 and 2.,abdomen:  no organomegaly.  no tenderness.  normal bowel sounds.,neurologic:  intact.,musculoskeletal:  left knee reveals a range of -10 degrees extension, 126 flexion.  his extensor mechanism is intact.  there is mild varus.  he has good stability at 30 degrees of flexion.  lachman's and posterior drawer are negative.  he has good muscle turgor.  dorsalis pedis pulse 2+.,diagnostics:  ,x-rays revealed severe bilateral knee djd with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,impression:,1.  bilateral knee degenerative joint disease.,2.  significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.",26
"history of present illness:,  patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  he did not note any immediate reaction.  since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  he denies any sensation of tongue swelling or difficulty swallowing.,the patient states he was stung approximately one month ago without any serious reaction.  he did windup taking benadryl at that time.  he has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,allergies: , he does have medication intolerances to sulfa drugs (headache), morphine (nausea and vomiting), and toradol (ulcer).,social history: , patient is married and is a nonsmoker and lives with his wife, who is here with him.,nursing notes were reviewed with which i agree.,physical examination,vital signs:  temp and vital signs are all within normal limits.,general:  in general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,heent:  head is normocephalic and atraumatic.  the face shows no edema.  the tongue is not swollen and the airway is widely patent.,neck:  no stridor.,heart:  regular rate and rhythm without murmurs, rubs, or gallops.,lungs:  clear without rales, rhonchi, or wheezes.,extremities:  upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  there was some slight edema of the fourth digit, on which he still is wearing his wedding band.  the right hand shows no reaction.  the right knee is not swollen either.,the left fourth digit was wrapped in a rubber tourniquet to express the edema and using some surgilube, i was able to remove his wedding band without any difficulty.  patient was given claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  i did explain to him that his swelling and redness may progress over the next few days.,assessment: , local reaction secondary to insect sting.,plan: , the patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  i did urge him to use claritin 10 mg once daily until the redness and swelling has gone.  i did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  if he is not improved in the next four days, follow up with his pcp for a re-exam.",15
"chief complaint:,  patient af is a 50-year-old hepatitis c positive african-american man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,history of present illness: , af's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  he has not eaten anything, and has vomited 8 times.  af reports 10/10 pain in the llq.,past medical history:,  af's past medical history is significant for an abdominal injury during the vietnam war which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis c positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, hodgkin's disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and ""crack chest pain"" ,past surgical history: , af has had multiple abdominal surgeries, including bill roth procedure type 1 (partial gastrectomy) during vietnam war, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,medications:,  none.,allergies:,  iodine, iv contrast (anaphylaxis), and seafood/shellfish.,family history:,  noncontributory.,social history:,  af was born and raised in san francisco.  his father was an alcoholic.  he currently lives with his sister, and does not work; he collects a pension.,health-related behaviors:,  af reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,review of systems: , noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,physical exam:,vital signs:  t:  37.1",5
"admission diagnosis:,  end-stage renal disease (esrd).,discharge diagnosis: , end-stage renal disease (esrd).,procedure:,  cadaveric renal transplant.,history of present illness: , this is a 46-year-old gentleman with end-stage renal disease (esrd) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,past medical history:  ,1.  diabetes mellitus diagnosed 12 years ago.,2.  hypertension.,3.  coronary artery disease with a myocardial infarct in september of 2006.,4.  end-stage renal disease.,past surgical history: , coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,social history:  ,the patient denies tobacco or ethanol use.,family history:,  hypertension.,physical examination:  ,general:  the patient was alert and oriented x3 in no acute distress, healthy-appearing male.,vital signs:  temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,cardiovascular:  regular rate and rhythm.,pulmonary:  clear to auscultation bilaterally.,abdomen:  soft, nontender, and nondistended with positive bowel sounds.,extremities:  no clubbing, cyanosis, or edema.,pertinent laboratory data: , white blood cell count 6.4, hematocrit 34.6, and platelet count 182.  sodium 137, potassium 5.4, bun 41, creatinine 7.9, and glucose 295.  total protein 6.5, albumin 3.4, ast 51, alt 51, alk phos 175, and total bilirubin 0.5.,course in hospital: , the patient was admitted postoperatively to the surgical intensive care unit.  initially, the patient had a decrease in hematocrit from 30 to 25.  the patient's hematocrit stabilized at 25.  during the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  the patient was making excellent urine throughout his stay.  the patient's jackson-pratt drain was removed on postoperative day #1 and he was moved to the floor.  the patient was advanced in diet appropriately.  the patient was started on prograf by postoperative day #2.  initial prograf levels came back high at 18.  the patient's prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  during the patient's stay, the patient received four total doses of thymoglobulin.  today, he will complete his final dose of thymoglobulin prior to being discharged.  in addition, today, the patient has an elevated blood pressure of 198/96.  the patient is being given an extra dose of metoprolol for this blood pressure.  in addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  these labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,discharge instructions: , the patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  he is discharged on a low-potassium diet with activity as tolerated.  he is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  the patient will be followed up in the transplant clinic at abcd tomorrow, at which time, his labs will be rechecked.  the patient's prograf levels at the time of discharge are pending; however, given that his prograf dose was decreased, he will be followed tomorrow at the renal transplant clinic.",20
"preop diagnosis: , basal cell ca.,postop diagnosis:,  basal cell ca.,location: , mid parietal scalp.,preop size:,  1.5 x 2.9 cm,postop size:,  2.7 x 2.9 cm,indication:,  poorly defined borders.,complications:,  none.,hemostasis:, electrodessication.,planned reconstruction:,  simple linear closure.,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.",8
"history of present illness: , the patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at hospital.  he was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,preoperative diagnoses: , left angle and right body mandible fractures.,postoperative diagnoses: , left angle and right body mandible fractures.,procedure: , closed reduction of mandible fractures with erich arch bars and elastic fixation.,anesthesia:,  general nasotracheal.,complications:,  none.,condition:,  stable to pacu.,description of procedure: , the patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars.  gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires.  after the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable.  the throat pack was then removed.  an ng tube was then passed and approximately 50 cc of stomach contents were suctioned out.,the elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the pacu in stable condition.",37
"preoperative diagnoses:,1.  acute pain.,2.  fever postoperatively.,postoperative diagnosis:,1.  acute pain.,2.  fever postoperatively.,3.  hemostatic uterine perforation.,4.  no bowel or vascular trauma.,procedure performed:,1.  diagnostic laparoscopy.,2.  rigid sigmoidoscopy by dr. x.,anesthesia: , general endotracheal.,complications: , none.,estimated blood loss: , scant.,specimen:,  none.,indications:  ,this is a 17-year-old african-american female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03.  the patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2.  the patient denied any nausea, vomiting or diarrhea.  she does complain of some frequent urination.  her vaginal bleeding is minimal.,findings: , on bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated.  on laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus.  there is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac.  the bilateral tubes and ovaries appeared normal.  there is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap.  there is no evidence of injury to the bowel or pelvic sidewall.  the liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,procedure: , after consent was obtained, the patient was taken to the operating room where general anesthetic was administered.  the patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  a sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  the uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed.  gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  veress needle was placed through this incision and the gas turned on.  when good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  a 11 mm trocar was then placed through this incision.  the camera was placed with the above findings noted.  a 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline.  a blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs.  the serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline.  at this point, dr. x was consulted.  he performed a rigid sigmoidoscopy, please see his dictation for further details.  there does not appear to be any evidence of colonic injury.  the saline in the pelvis was then suctioned out using nezhat-dorsey.  all instruments were removed.  the 5 mm trocar was removed under direct visualization with excellent hemostasis noted.  the camera was removed and the abdomen was allowed to desufflate.  the 11 mm trocar introducer was replaced and the trocar removed.  the skin was then closed with #4-0 undyed vicryl in a subcuticular fashion.  approximately 10 cc of 0.25% marcaine was injected into the incision sites for postoperative pain relief.  steri-strips were then placed across the incision.  the uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted.  the patient tolerated the procedure well.  sponge, lap, and needle counts were correct at the end of the procedure.  the patient was taken to the recovery room in satisfactory condition.,she will be followed immediately postoperatively within the hospital and started on iv antibiotics.",14
"preoperative diagnosis: , a 10-1/2 week pregnancy, spontaneous, incomplete abortion.,postoperative diagnosis:,  a 10-1/2 week pregnancy, spontaneous, incomplete abortion.,procedure: , exam under anesthesia with uterine suction curettage.,anesthesia: , spinal.,estimated blood loss: , less than 10 cc.,complications:,  none.,drains:,  none.,condition:,  stable.,indications:  ,the patient is a 29-year-old gravida 5, para 1-0-3-1, with an lmp at 12/18/05.  the patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  she began to have heavy vaginal bleeding and intense lower pelvic cramping.  she was seen in the emergency room where she was found to be hemodynamically stable.  on pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  there were bulging membranes protruding through the dilated cervix.  these symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  these findings were reviewed with her and options for treatment discussed.  she elected to proceed with an exam under anesthesia with uterine suction curettage.  the risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,procedure:  ,the patient was taken to the operating room where she was placed in the seated position.  a spinal anesthetic was successfully administered.  she was then moved to a dorsal lithotomy position.  she was prepped and draped in the usual fashion for the procedure.  after adequate spinal level was confirmed, a bimanual exam was again performed.  this revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  the previously noted cervical exam was confirmed.  the weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  this solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  the anterior cervical lip was then attached with a ring clamp.  the tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  the tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  the placental tissue was then gently tractioned out as well.  a size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  with the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  the sharp curette was then utilized to probe the endometrial surface.  a small amount of additional tissue was then felt in the posterior uterine wall.  this was curetted free.  a second pass was then made with a vacuum curette.  again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  a final pass was then made with a suction curette.,the ring clamp was then removed from the anterior cervical lip.  there was only a small amount of bleeding following the curettage.  the weighted speculum was then removed as well.  the bimanual exam was repeated and good involution was noted.  the patient was taken down from the dorsal lithotomy position.  she was transferred to the recovery room in stable condition.  the sponge and instrument count was performed and found to be correct.  the specimen of products of conception and 10-week fetus were submitted to pathology for further evaluation.  the estimated blood loss for the procedure is less than 10 ml.",23
"date of admission:,  mm/dd/yyyy.,date of discharge: , mm/dd/yyyy.,referring physician: , ab cd, m.d.,attending physician at discharge:,  x y, m.d.,admitting diagnoses:,1.  ewing sarcoma.,2.  anemia.,3.  hypertension.,4.  hyperkalemia.,procedures during hospitalization:  ,cycle seven ifosfamide, mesna, and vp-16 chemotherapy.,history of present illness: , ms. xxx is a pleasant 37-year-old african-american female with the past medical history of ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  she presented initially with a left frontal orbital swelling to dr. xyz on mm/dd/yyyy.  a biopsy revealed small round cells and repeat biopsy on mm/dd/yyyy also showed round cells consistent with ewing sarcoma, genetic analysis indicated a t1122 translocation.  mri on mm/dd/yyyy showed a 4 cm soft tissue mass without bony destruction.  ct showed similar result.  the patient received her first cycle of chemotherapy on mm/dd/yyyy.  on mm/dd/yyyy, she was admitted to the ed with nausea and vomitting and was admitted to the hematology and oncology a service following her first course of chemotherapy.  she had her last course of chemotherapy on mm/dd/yyyy followed by radiation treatment to the ethmoid sinuses on mm/dd/yyyy.,hospital course: ,1.  ewing sarcoma, she presented for cycle seven of vp-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  she was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission.",15
"exam:  ,three views of the right foot.,reason for exam: , right foot trauma.,findings: , three views of the right foot were obtained.  there are no comparison studies.  there is no evidence of fractures or dislocations.  no significant degenerative changes or obstructive osseous lesions were identified.  there are no radiopaque foreign bodies.,impression: , negative right foot.",32
"chief complaint:,  toothache.,history of present illness:  ,this is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  complains of new tooth pain.  the patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  the patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  the patient denies any other problems or complaints.  the patient denies any recent illness or injuries.  the patient does have oxycontin and vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,review of systems: , constitutional:  no fever or chills.  no fatigue or weakness.  no recent weight change.  heent:  no headache, no neck pain, the toothache pain for the past three days as previously mentioned.  there is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  the patient denies any rhinorrhea.  no sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  cardiovascular:  no chest pain.  respirations:  no shortness of breath or cough.  gastrointestinal:  no abdominal pain.  no nausea or vomiting.  genitourinary:  no dysuria.  musculoskeletal:  no back pain.  no muscle or joint aches.  skin:  no rashes or lesions.  neurologic:  no vision or hearing change.  no focal weakness or numbness.  normal speech.  hematologic/lymphatic:  no lymph node swelling has been noted.,past medical history: , chronic knee pain.,current medications: , oxycontin and vicodin.,allergies:,  penicillin and codeine.,social history: , the patient is still a smoker.,physical examination:,  vital signs:  temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  constitutional:  the patient is well nourished and well developed.  the patient is a little overweight but otherwise appears to be healthy.  the patient is calm, comfortable, in no acute distress, and looks well.  the patient is pleasant and cooperative.  heent:  eyes are normal with clear conjunctiva and cornea bilaterally.  there is no icterus, injection, or discharge.  pupils are 3 mm and equally round and reactive to light bilaterally.  there is no absence of light sensitivity or photophobia.  extraocular motions are intact bilaterally.  ears are normal bilaterally without any sign of infection.  there is no erythema, swelling of canals.  tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  nose is normal without rhinorrhea or audible congestion.  there is no tenderness over the sinuses.  neck:  supple, nontender, and full range of motion.  there is no meningismus.  no cervical lymphadenopathy.  no jvd.  mouth and oropharynx shows multiple denture and multiple dental caries.  the patient has tenderness to tooth #12 as well as tooth #21.  the patient has normal gums.  there is no erythema or swelling.  there is no purulent or other discharge noted.  there is no fluctuance or suggestion of abscess.  there are no new dental fractures.  the oropharynx is normal without any sign of infection.  there is no erythema, exudate, lesion or swelling.  the buccal membranes are normal.  mucous membranes are moist.  the floor of the mouth is normal without any abscess, suggestion of ludwig's syndrome.  cardiovascular:  heart is regular rate and rhythm without murmur, rub, or gallop.  respirations:  clear to auscultation bilaterally without shortness of breath.  gastrointestinal:  abdomen is normal and nontender.  musculoskeletal:  no abnormalities are noted to back, arms and legs.  the patient has normal use of his extremities.  skin:  no rashes or lesions.  neurologic:  cranial nerves ii through xii are intact.  motor and sensory are intact to the extremities.  the patient has normal speech and normal ambulation.  psychiatric:  the patient is alert and oriented x4.  normal mood and affect.  hematologic/lymphatic:  no cervical lymphadenopathy is palpated.,emergency department course: , the patient did request a pain shot and the patient was given dilaudid of 4 mg im without any adverse reaction.,diagnoses:,1.  odontalgia.,2.  multiple dental caries.,condition upon disposition:  ,stable.,disposition: , to home.,plan: , the patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  the patient was requested to have reevaluation within two days.  the patient was given a prescription for percocet and clindamycin.  the patient was given drug precautions for the use of these medicines.  the patient was offered discharge instructions on toothache but states that he already has it.  he declined the instructions.  the patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.",7
"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.",22
"history of present illness:,  this is a 55-year-old female with a history of i-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  she also has a history of fibromyalgia, inflammatory bowel disease, crohn disease, copd, and disc disease as well as thyroid disorder.  she has noticed increasing abdominal girth as well as increasing edema in her legs.  she has been on norvasc and lisinopril for years for hypertension.  she has occasional sweats with no significant change in her bowel status.  she takes her thyroid hormone apart from her synthroid.  she had been on generic for the last few months and has had difficulty with this in the past.,medications: , include levothyroxine 300 mcg daily, albuterol, asacol, and prilosec.  her amlodipine and lisinopril are on hold.,allergies:,  include iv dye, sulfa, nsaids, compazine, and demerol.,past medical history:,  as above includes i-131-induced hypothyroidism, inflammatory bowel disease with crohn, hypertension, fibromyalgia, copd, and disc disease.,past surgical history: , includes a hysterectomy and a cholecystectomy.,social history: , she does not smoke or drink alcohol.,family history: , positive for thyroid disease but the sister has graves disease, as well a sister with hashimoto thyroiditis.,review of systems: , positive for fatigue, sweats, and weight gain of 20 pounds.  denies chest pain or palpitations.  she has some loosening stools, but denies abdominal pain.  complains of increasing girth and increasing leg swelling.,physical examination:,general:  she is an obese female.,vital signs:  blood pressure 140/70 and heart rate 84.  she is afebrile.,heent:  she has no periorbital edema.  extraocular movements were intact.  there was moist oral mucosa.,neck:  supple.  her thyroid gland is atrophic and nontender.,chest:  good air entry.,cardiovascular:  regular rate and rhythm.,abdomen:  benign.,extremities:  showed 1+ edema.,neurologic:  she was awake and alert.,laboratory data:,  tsh 0.28, free t4 1.34, total t4 12.4 and glucose 105.,impression/plan:,  this is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  hypothyroidism is secondary to radioactive iodine for graves disease many years ago.  she is clinically and biochemically euthyroid.  her tsh is mildly suppressed, but her free t4 is normal and with her weight gain i will not decrease her dose of levothyroxine.  i will continue on 300 mcg daily of synthroid.  if she wanted to lose significant weight, i shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.",13
"preoperative diagnosis:,  left inguinal hernia.,postoperative diagnosis: , left inguinal hernia, direct.,procedure: , left inguinal herniorrhaphy, modified bassini.,description of procedure:  ,the patient was electively taken to the operating room.  in same day surgery, dr. x applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  the cord was isolated and protected.  it was dissected out.  the lipoma of the cord was removed and the sac was high ligated.  the main hernia was a direct hernia due to weakness of the floor.  a bassini repair was performed.  we used a number of interrupted sutures of 2-0 tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,the external oblique muscle was approximated same as the soft tissue with vicryl and then the skin was closed with subcuticular suture of monocryl.  the dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.",37
"family history and social history:,  reviewed and remained unchanged.,medications:,  list remained unchanged including plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, lasix, insulin and simvastatin.,allergies:,  she has no known drug allergies.,fall risk assessment: , completed and there was no history of falls.,review of systems:  ,full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  rest of them was negative.,physical examination:,vital signs:  today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,general:  she was a pleasant person in no acute distress.,heent:  normocephalic and atraumatic.  no dry mouth.  no palpable cervical lymph nodes.  her conjunctivae and sclerae were clear.,neurological examination:,  remained unchanged.,mental status:  normal.,cranial nerves:  mild decrease in the left nasolabial fold.,motor:  there was mild increased tone in the left upper extremity.  deltoids showed 5-/5.  the rest showed full strength.  hip flexion again was 5-/5 on the left.  the rest showed full strength.,reflexes:  reflexes were hypoactive and symmetrical.,gait:  she was mildly abnormal.  no ataxia noted.  wide-based, ambulated with a cane.,impression: , status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  she is planned for surgical intervention for the internal carotid artery.,recommendations: , at this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  she will continue to follow with endocrinology for diabetes and thyroid problems.  i have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and i have discussed with ms. a and her daughter to give us a call for post surgical recovery.  i will see her back in about four months or sooner if needed.",21
"general: , alert, well developed, in no acute distress.,mental status: , judgment and insight appropriate for age.  oriented to time, place and person.  no recent loss of memory.  affect appropriate for age.,eyes:  ,pupils are equal and reactive to light.  no hemorrhages or exudates.  extraocular muscles intact.,ear, nose and throat: , oropharynx clean, mucous membranes moist.  ears and nose without masses, lesions or deformities.  tympanic membranes clear bilaterally.  trachea midline.  no lymph node swelling or tenderness.,respiratory:  ,clear to auscultation and percussion.  no wheezing, rales or rhonchi.,cardiovascular: , heart sounds normal.  no thrills.  regular rate and rhythm, no murmurs, rubs or gallops.,gastrointestinal: , abdomen soft, nondistended.  no pulsatile mass, no flank tenderness or suprapubic tenderness.  no hepatosplenomegaly.,neurologic: , cranial nerves ii-xii grossly intact.  no focal neurological deficits.  deep tendon reflexes +2 bilaterally.  babinski negative.  moves all extremities spontaneously.  sensation intact bilaterally.,skin: , no rashes or lesions.  no petechia.  no purpura.  good turgor.  no edema.,musculoskeletal: , no cyanosis or clubbing.  no gross deformities.  capable of free range of motion without pain or crepitation.  no laxity, instability or dislocation.,bone: , no misalignment, asymmetry, defect, tenderness or effusion.  capable of from of joint above and below bone.,muscle:  ,no crepitation, defect, tenderness, masses or swellings.  no loss of muscle tone or strength.,lymphatic:,  palpation of neck reveals no swelling or tenderness of neck nodes.  palpation of groin reveals no swelling or tenderness of groin nodes.",15
"cc:, confusion and slurred speech.,hx , (primarily obtained from boyfriend): this 31 y/o rhf experienced a ""flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found ""passed out"" in bed, and when awoken appeared confused, and lethargic. she apparently recovered within 24 hours. for two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). she left a stove on.,she began slurring her speech 2 days prior to admission. on the day of presentation she developed right facial weakness and began stumbling to the right. she denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. there was no history of illicit drug/etoh use or head trauma.,pmh:, migraine headache.,fhx: , unremarkable.,shx: ,divorced. lives with boyfriend. 3 children alive and well. denied tobacco/illicit drug use. rarely consumes etoh.,ros:, irregular menses.,exam: ,bp118/66.  hr83. rr 20. t36.8c.,ms: alert and oriented to name only. perseverative thought processes. utilized only one or two word answers/phrases. non-fluent. rarely followed commands. impaired writing of name.,cn: flattened right nasolabial fold only.,motor: mild weakness in rue manifested by pronator drift. other extremities were full strength.,sensory: withdrew to noxious stimulation in all 4 extremities.,coordination: difficult to assess.,station: right pronator drift.,gait: unremarkable.,reflexes: 2/2bue, 3/3ble, plantars were flexor bilaterally.,general exam: unremarkable.,initial studies:, cbc, gs, ua, pt, ptt, esr, crp, ekg were all unremarkable. outside hct showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,course: ,mri brian scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left mca distribution suggesting slow flow. the latter suggested a vasculopathy such as moya moya, or fibromuscular dysplasia. hiv, ana, anti-cardiolipin antibody titer, cardiac enzymes, tfts, b12, and cholesterol studies were unremarkable.,she underwent a cerebral angiogram on 2/12/92. this revealed an occlusion of the left mca just distal to its origin. the distal distribution of the left mca filled on later films through collaterals from the left aca. there was also an occlusion of the right mca just distal to the temporal branch. distal branches of the right mca filled through collaterals from the right aca. no other vascular abnormalities were noted. these findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as moya moya disease. she was subsequently given this diagnosis. neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. she had long latencies responding and understood only simple questions. affect was blunted and there was distinct lack of concern regarding her condition. she was subsequently discharged home on no medications.,in 9/92 she was admitted for sudden onset right hemiparesis and mental status change. exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. ob/gyn exam including cervical biopsy, and abdominal/pelvic ct scanning revealed stage iv squamous cell cancer of the cervix. she died 9/24/92 of cervical cancer.",32
"chief complaint (1/1):, this 59 year old female presents today complaining that her toenails are discolored, thickened, and painful. duration: condition has existed for 6 months. severity: severity of condition is worsening.,allergies: ,patient admits allergies to dairy products, penicillin.,medication history:, none.,past medical history:, past medical history is unremarkable.,past surgical history:, patient admits past surgical history of eye surgery in 1999.,social history:, patient denies alcohol use, patient denies illegal drug use, patient denies std history, patient denies tobacco use.,family history:, unremarkable.,review of systems:, psychiatric: (+) poor sleep pattern, respiratory: (+) breathing difficulties, respiratory symptoms.,physical exam:, patient is a 59 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. toenails 1-5 bilateral appear crumbly, discolored - yellow, friable and thickened.,cardiovascular: dp pulses palpable bilateral. pt pulses palpable bilateral. cft immediate. no edema observed.  varicosities are not observed.,skin: skin temperature of the lower extremities is warm to cool, proximal to distal. no skin rash, subcutaneous nodules, lesions or ulcers observed.,neurological: touch, pin, vibratory and proprioception sensations are normal. deep tendon reflexes normal.,musculoskeletal: muscle strength is 5/5 for all groups tested. muscle tone is normal. inspection and palpation of bones, joints and muscles is unremarkable.,test results:, no tests to report at this time.,impression:, onychomycosis.,plan:, debrided 10 nails.,prescriptions:, penlac dosage: 8% topical solution sig:",5
"subjective:,  a 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  also, i cleaned out his maxillary sinuses.  symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  the surgery went well, and i had planned for him to stay overnight, but mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  he finished up his augmentin, by a day or two later he was off the lortab.  mom has not noticed any unusual voice change.  no swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  he has not had any nasal discharge or ever had any bleeding.  he seems to be breathing better.,objective:,  exam looks good.  the pharynx is well healed.  tongue mobility is normal.  voice sounds clear.  nasal passages reveal no discharge or crusting.,recommendation:,  i told mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  he says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  it is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  the pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,i am glad he has healed up well.  there are no other restrictions or limitations.  i told mom, i had written to dr. xyz to let her know of the findings.  the child will continue his regular followup visits with his family doctor, and i told mom i would be happy to see him anytime if needed.  he did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.",24
"allowed conditions:,  726.31 right medial epicondylitis; 354.0 right carpal tunnel syndrome.,contested conditions:,  354.2 right cubital tunnel syndrome.,employer:,  abcd,  ,i examined xxxxx today for the allowed conditions and also the contested conditions listed above.  i obtained her history from company medical records and performed an examination.  she is a 38-year-old laborer who states that she was injured on april 26, 2006, which according to the froi (the injury occurred over a period of time from performing normal job processes such as putting bumpers on cars, gas caps and doors on cars).  she denies having any symptoms prior to the accident april 26, 2006.  she is right handed.  she used a tennis elbow brace, hand exercises, physical therapy, and vicodin.  she received treatment from dr. x and also dr. y,diagnostic studies:,  june 27, 2006, emg and nerve conduction velocity right upper extremity showed a moderate right carpal tunnel syndrome.  no evidence of a right cervical radiculopathy or ulnar neuropathy at the wrist or elbow.  january 29, 2007, emg right upper extremity was normal and there was a normal nerve conduction velocity.  at the time of the examination, she complained of a constant pain in the olecranon and distal triceps with tingling in the right long, ring and small fingers, and night pain.  the pain was accentuated by gripping or opening the jar.  she is taking four aleve a day and currently does not have any other treatment.,records reviewed: , injury and illness incident report, us healthworks records; z physician review; y office notes; x office notes who noted that on examination of the right elbow that the ulnar nerve subluxed with flexion and extension of the elbow.,examination: , examination of her right elbow revealed no measurable atrophy of the upper arm.  she was markedly tender over the medial epicondyle, but also the olecranon and distal process and she was exquisitely tender over the ulnar nerve.  i did not detect subluxation of the ulnar nerve with flexion and extension.  with this, she was extremely tender in this area.  there is no instability of the elbow.  range of motion was 0 to 145 degrees, flexion 90 degrees of pronation and supination.  the elbow flexion test was positive.  there is normal motor power in the elbow and also on the right hand, specifically in the ulnar intrinsics.  there was diminished sensation on the right ring and small fingers, specifically the ulnar side of the ring finger of the entire small finger.  there was no wasting of the intrinsics.  no clawing of the hand.  examination of the right wrist revealed extension 45 degrees, flexion 45 degrees, radial deviation 15 degrees, and ulnar deviation 35 degrees.  she was tender over the dorsum of the hand over the ulnar head and the volar aspect of the wrist.  wrist flexion causes paresthesias on the right ring and small fingers.  grasp was weak.  there was no sign of causalgia, but no measurable atrophy of the forearm.  no reflex changes.,question:,  ms. xxxxx has filed an application of additional allowance of right cubital tunnel syndrome.  based on the current objective findings, mechanism of injury, medical records or diagnostic studies, does the medical evidence support the existence of the requested condition?,answer:,  yes.  she has a positive elbow flexion test and she is markedly tender over the ulnar nerve at the elbow and also has diminished sensation in the ulnar nerve distribution, specifically in the entire right small finger and the ulnar half of the ring finger.  i did not find the subluxation of the ulnar nerve with flexion and extension with dr. x did previously find on his examination.,question: , if you find these conditions exist, are they a direct and proximate result of april 26, 2006, injury?,answer: , yes.  repeated flexion and extension would irritate the ulnar nerve particularly if it was subluxing which it could very well have which dr. x objectively identified on his examination.  therefore, i believe it is a direct and proximate result of april 26, 2006, injury.,question: , do you find that ms. xxxxx's injury or disability is caused by natural deterioration of tissue, organ or part of the body?,answer: , no.,question:,  in addition, if you find that the condition exists, are there non-occupational activities or intervening injuries that could have contributed to ms. xxxxx's condition?,answer: , it is possible that direct injury to the ulnar nerve at the elbow could cause this syndrome; however, there is no history of this and the records do not indicate an injury of this type.,question: ,",5
"preoperative diagnosis:  ,1.  right cubital tunnel syndrome.,2.  right carpal tunnel syndrome.,3.  right olecranon bursitis.,postoperative diagnosis:,  ,1.  right cubital tunnel syndrome.,2.  right carpal tunnel syndrome.,3.  right olecranon bursitis.,procedures:,  ,1.  right ulnar nerve transposition.,2.  right carpal tunnel release.,3.  right excision of olecranon bursa.,anesthesia:,  general.,blood loss:,  minimal.,complications:,  none.,findings: , thickened transverse carpal ligament and partially subluxed ulnar nerve.,summary: , after informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  after uneventful general anesthesia was obtained, his right arm was sterilely prepped and draped in normal fashion.  after elevation and exsanguination with an esmarch, the tourniquet was inflated.  the carpal tunnel was performed first with longitudinal incision in the palm carried down through the skin and subcutaneous tissues.  the palmar fascia was divided exposing the transverse carpal ligament, which was incised longitudinally.  a freer was then inserted beneath the ligament, and dissection was carried out proximally and distally.,after adequate release has been formed, the wound was irrigated and closed with nylon.  the medial approach to the elbow was then performed and the skin was opened and subcutaneous tissues were dissected.  a medial antebrachial cutaneous nerve was identified and protected throughout the case.  the ulnar nerve was noted to be subluxing over the superior aspect of the medial epicondyle and flattened and inflamed.  the ulnar nerve was freed proximally and distally.  the medial intramuscular septum was excised and the flexor carpi ulnaris fascia was divided.  the intraarticular branch and the first branch to the scu were transected; and then the nerve was transposed, it did not appear to have any significant tension or sharp turns.  the fascial sling was made from the medial epicondyle and sewn to the subcutaneous tissues and the nerve had good translation with flexion and extension of the elbow and not too tight.  the wound was irrigated.  the tourniquet was deflated and the wound had excellent hemostasis.  the subcutaneous tissues were closed with #2-0 vicryl and the skin was closed with staples.  prior to the tourniquet being deflated, the subcutaneous dissection was carried out over to the olecranon bursa, where the loose fragments were excised with a rongeurs as well as abrading the ulnar cortex and excision of hypertrophic bursa.  a posterior splint was applied.  marcaine was injected into the incisions and the splint was reinforced with tape.  he was awakened from the anesthesia and taken to recovery room in a stable condition.  final needle, instrument, and sponge counts were correct.",37
"chief complaint:,  gi bleed.,history of present illness:,  the patient is an 80-year-old white female with history of atrial fibrillation, on coumadin, who presented as outpatient, complaining of increasing fatigue.  cbc revealed microcytic anemia with hemoglobin of 8.9.  stool dark brown, strongly ob positive.  the patient denied any shortness of breath.  no chest pain.  no gi complaints.  the patient was admitted to abcd for further evaluation.,past medical history:  ,significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,physical examination:,general:  the patient is in no acute distress.,vital signs:  stable.,heent:  benign.,neck:  supple.  no adenopathy.,lungs:  clear with good air movement.,heart:  irregularly regular.  no gallops.,abdomen:  positive bowel sounds, soft, and nontender.  no masses or organomegaly.,extremities:  1+ lower extremity edema bilaterally.,hospital course: , the patient underwent upper endoscopy performed by dr. a, which revealed erosive gastritis.  colonoscopy did reveal diverticulosis as well as polyp, which was resected.  the patient tolerated the procedure well.  she was transfused, and prior to discharge hemoglobin was stable at 10.7.  the patient was without further gi complaints.  coumadin was held during hospital stay and recommendations were given by gi to hold coumadin for an additional three days after discharge then resume.  the patient was discharged with outpatient pmd, gi, and cardiology followup.,discharge diagnoses:,1.  upper gastrointestinal bleed.,2.  anemia.,3.  atrial fibrillation.,4.  non-insulin-dependent diabetes mellitus.,5.  hypertension.,6.  hypothyroidism.,7.  asthma.,condition upon discharge: , stable.,medications: , feosol 325 mg daily, multivitamins one daily, protonix 40 mg b.i.d., kcl 20 meq daily, lasix 40 mg b.i.d., atenolol 50 mg daily, synthroid 80 mcg daily, actos 30 mg daily, mevacor 40 mg daily, and lisinopril 20 mg daily.,allergies:,  none.,diet: , 1800-calorie ada.,activity: , as tolerated.,followup: , the patient to hold coumadin through weekend.  followup cbc and inr were ordered.  outpatient followup as arranged.",14
"precatheterization diagnosis (es):, hypoplastic left heart, status post norwood procedure and glenn shunt.,postcatheterization diagnosis (es):,1. hypoplastic left heart.,a. status post norwood.,b. status post glenn.,2. left pulmonary artery hypoplasia.,3. diminished right ventricular systolic function.,4. trivial neo-aortic stenosis.,5. trivial coarctation.,6. flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,procedure (s):, right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,i. procedures:, xxxxxx was brought to the catheterization lab and was anesthetized by anesthesia. he was intubated. his supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. the patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. xylocaine was administered in the right femoral area. a 6-french sheath was introduced into the right femoral vein percutaneously without complication. a 4-french sheath was introduced into the right femoral artery percutaneously without complication. a 4-french pigtail catheter was introduced and passed to the abdominal aorta.,dr. hayes, using the siterite device, introduced a 5-french sheath into the right internal jugular vein without complication.,a 5-french wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. this catheter would not pass to the right pulmonary artery. the wedge catheter was removed. a 5-french ima catheter was then introduced and passed to the right pulmonary artery. after right pulmonary artery pressure was measured, this catheter was removed.,the 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: inferior vena cava, right atrium, left atrium, and right ventricle.,the previously introduced 4 pigtail catheter was advanced to the ascending aorta. simultaneous right ventricular and ascending aortic pressures were measured. a pullback from ascending aorta to descending aorta was then performed. simultaneous measurements of right ventricular and descending aortic pressures were measured.,the wedge catheter was removed. a 5-french berman catheter was advanced down the glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to glenn shunt was performed. an injection was then performed using omnipaque 16 ml at 8 ml per second with the berman catheter positioned in the glenn shunt. the 5-french berman was removed.,a 6-french berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. a right ventriculogram was performed using omnipaque 18 ml at 12 ml per second. the berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using omnipaque 10 ml at 8 ml per second.,the 4-french pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using omnipaque 16 ml at 12 ml per second.,following the ascending angiograms, two kidneys and a bladder were noted. the catheters and sheaths were removed, and hemostasis was obtained by direct pressure. the estimated blood loss was less than 30 ml, and none was replaced. heparin was administered following placement of all of the sheaths. pulse oximetry saturation, pulse in the right foot, and ekg were monitored continuously.,ii. pressures:,a. left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, a6 to 9, v6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,b. ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,c. pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to glenn, mean of 12 to mean of 13; right pulmonary artery to glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,interpretation:, right and left pulmonary artery pressures are appropriate for this situation. there is a gradient of, at most, 2 mmhg on pullback from both the right and left pulmonary arteries to the glenn shunt. the left atrial mean pressure is normal. right ventricular end-diastolic pressure is, at most, slightly elevated. there is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. there is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. on pullback from ascending to descending aorta, there is a 6-mmhg gradient between the two. systemic blood pressure is normal.,iii. oximetry:, superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,interpretation:, systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. the saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,iv. special procedure (s):, none done.,v. calculations:,please see the calculation sheet. calculations were based upon an assumed oxygen consumption. the _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. using the above information, the pulmonary to systemic flow ratio was 0.6. systemic blood flow was 5.1 liters per minute per meter squared. pulmonary blood flow was 3.2 liters per minute per meter squared. systemic resistance was 9.8 wood's units times meter squared, which is mildly diminished. pulmonary resistance was 2.5 wood's units times meter squared, which is in the normal range.,vi. angiography:, the injection to the glenn shunt demonstrates a wide-open glenn connection. the right pulmonary artery is widely patent, without stenosis. the proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. the right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. the aorta at the diaphragm on a later injection was 5.5 mm. there is a small collateral off the innominate vein passing to the left upper lobe. flow to both upper lobes is diminished versus lower lung fields. there is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. there is normal return of the left lower pulmonary vein and left upper pulmonary vein. there is some reflux of dye into the inferior vena cava from the right atrium.,the right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. the calculated ejection fraction from the lao projection is only mildly diminished at 59%. there is no significant tricuspid regurgitation. the neo-aortic valve appears to open well with no stenosis. the ascending aorta is dilated. there is mild narrowing of the aorta at the isthmal area. on some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of norwood reconstruction. there is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,the inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,the ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. the coronary arteries are poorly seen. again, a portion of the aorta appears to be partially duplicated. there is faint opacification of the left upper lung from collateral blood flow. the above-mentioned narrowing of the aortic arch is again noted.",37
"preoperative diagnosis: , recurrent severe right auricular hematoma.,postoperative diagnosis: , recurrent severe right auricular hematoma.,title of procedure:,  incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,anesthesia: , xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 ml.,complications:,  none.,findings: , approximately 5 ml of serosanguineous drainage.,procedure: , the patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by dr. x on 05/23/2008 for a large near 100% auricular hematoma.  she presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by dr. x.  it was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  consent was obtained.  the patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,the area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 ml of serosanguineous drainage was noted.  a through-and-through keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  she tolerated this procedure very well.",37
"subjective: , this is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  she says her asthma has been worse over the last three months.  she has been using her inhaler daily.  her allergies seem to be a little bit worse as well.  her husband has been hauling corn and this seems to aggravate things.  she has not been taking allegra daily but when she does take it, it seems to help somewhat.  she has not been taking her flonase which has helped her in the past.  she also notes that in the past she was on advair but she got some vaginal irritation with that.,she had been noticing increasing symptoms of irritability and pms around her menstrual cycle.  she has been more impatient around that time.  says otherwise her mood is normal during the rest of the month.  it usually is worse the week before her cycle and improves the day her menstrual cycle starts.  menses have been regular but somewhat shorter than in the past.  occasionally she will get some spotting after her cycles.  she denies any hot flashes or night sweats with this.  in reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  her urine has not been rechecked.  she recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,review of systems: , as above.  no fevers, no headaches, no shortness of breath currently.  no chest pain or tightness.  no abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  occasional stress incontinence.  no muscle or joint pain.  no concerns about her skin.  no polyphagia, polydipsia or polyuria.,past medical history: , significant for asthma, allergic rhinitis and cervical dysplasia.,social history: , she is married.  she is a nonsmoker.,medications: , proventil and allegra.,allergies: , sulfa.,objective:,vital signs:  her weight is 151 pounds.  blood pressure is 110/60.  pulse is 72.  temperature is 97.1 degrees.  respirations are 20.,general:  this is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  affect is appropriate and is pleasant.,heent:  normocephalic, atraumatic.  tympanic membranes are clear.  conjunctivae are clear.  pupils are equal, round and reactive to light.  nares without turbinate edema.  oropharynx is nonerythematous.,neck:  supple without lymphadenopathy, thyromegaly, carotid bruit or jvd.,chest:  clear to auscultation bilaterally.,cardiovascular:  regular rate and rhythm without murmur.,abdomen:  soft, nontender, nondistended.  normoactive bowel sounds.  no masses or organomegaly to palpation.,extremities:  without cyanosis or edema.,skin:  without abnormalities.,breasts:  normal symmetrical breasts without dimpling or retraction.  no nipple discharge.  no masses or lesions to palpation.  no axillary masses or lymphadenopathy.,genitourinary:  normal external genitalia.  the walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  cervix is visualized without lesion.  she has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  no cervical motion tenderness.  no adnexal tenderness or fullness.,assessment/plan:,1.  asthma.  seems to be worse than in the past.  she is just using her proventil inhaler but is using it daily.  we will add flovent 44 mcg two puffs p.o. b.i.d.  may need to increase the dose.  she did get some vaginal irritation with advair in the past but she is willing to retry that if it is necessary.  may also need to consider singulair.  she is to call me if she is not improving.  if her shortness of breath worsens she is to call me or go into the emergency department.  we will plan on following up for reevaluation in one month.,2.  allergic rhinitis.  we will plan on restarting allegra and flonase daily for the time being.,3.  premenstrual dysphoric disorder.  she may have some perimenopausal symptoms.  we will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  hematuria.  likely this is secondary to urinary tract infection but we will repeat a ua to document clearing.  she does have some frequent dysuria but is not having it currently.,5.  cervical dysplasia.  pap smear is taken.  we will notify the patient of results.  if normal we will go back to yearly pap smear.  she is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  recommend she get 1200 mg of calcium and 400 u of vitamin d a day.",15
"history of present illness: , the patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  he states that for the past six months he has experienced cramps in his feet and hands.  he describes that the foot cramps are much more notable than the hand ones.  he reports that he develops muscle contractions of his toes on both feet.  these occur exclusively at night.  they may occur about three times per week.  when he develops these cramps, he stands up to relieve the discomfort.  he notices that the toes are in an extended position.  he steps on the ground and they seem to ""pop into place.""  he develops calf pain after he experiences the cramp.  sometimes they awaken him from his sleep.,he also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  these do not occur at night and are completely random.  he notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,he has never had any symptoms like this in the past.  he started taking bactrim about nine months ago.  he had taken this in the past briefly, but has never taken it as long as he has now.  he cannot think of any other possible contributing factors to his symptoms.,he has a history of hiv for 21 years.  he was taking antiretroviral medications, but stopped about six or seven years ago.  he reports that he was unable to tolerate the medications due to severe stomach upset.  he has a cd4 count of 326.  he states that he has never developed aids.  he is considering resuming antiretroviral treatment.,past medical history:,  he has diabetes, but this is well controlled.  he also has hepatitis c and hiv.,current medications: , he takes insulin and bactrim.,allergies: , he has no known drug allergies.,social history: , he lives alone.  he recently lost his partner.  this happened about six months ago.  he denies alcohol, tobacco, or illicit drug use.  he is now retired.  he is very active and walks about four miles every few days.,family history: , his father and mother had diabetes.,review of systems: , a complete review of systems was obtained and was negative except for as mentioned above.  this is documented in the handwritten notes from today's visit.,physical examination:,vital signs:  blood pressure 130/70",5
"he has no voiding complaints and no history of sexually transmitted diseases.,past medical history: , none.,past surgical history: , back surgery with a fusion of l5-s1.,medications: , he does take occasional percocet for his back discomfort.,allergies:,  he has no allergies.,social history:,  he is a smoker.  he takes rare alcohol.  his employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid.  he travels to anywhere for his work.  he is married with one son.,family history: , negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,review of systems:,  negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,physical examination,general:  the patient is afebrile.  his vital signs are stable.  he is 177 pounds, 5 feet, 8 inches.  blood pressure 144/66.  he is healthy appearing.  he is alert and oriented x 3.,heart:  regular rate and rhythm.,lungs:  clear to auscultation.,abdomen:  soft and nontender.  his penis is circumcised.  he has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock.  it is very obvious and apparent.  he also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber.  his testicles are descended bilaterally.  there are no masses.,assessment and plan: , this is likely molluscum contagiosum (genital warts) caused by hpv.  i did state to the patient that this is likely a viral infection that could have had a long incubation period.  it is not clear where this came from but it is most likely sexually transmitted.  he is instructed that he should use protected sex from this point on in order to try and limit the transmission.  regarding the actual lesion itself, i did mention that we could apply a cream of condylox, which could take up to a month to work.  i also offered him c02 laser therapy for the genital warts, which is an outpatient procedure.  the patient is very interested in something quick and effective such as a co2 laser procedure.  i did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions.  the patient understood this and still wished to proceed.  there is minimal risk otherwise except for those inherent in laser injury and accidental injury.  the patient understood and wished to proceed.",5
"preoperative diagnosis: , sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,postoperative diagnosis: , sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,anesthesia: , conscious sedation.,informed consent: , after adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal manipulation under anesthesia (mua).  the patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,indication:,  this patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,comments: , this patient understands the essence of the diagnosis and the reasons for the mua- the associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  alternatives to the procedure, including the course of the condition without mua, were discussed.  the patient understands the chances of success from undergoing mua and that no guarantees are made or implied regarding outcome.  the patient has given both verbal and written informed consent for the listed procedure.,procedure in detail: , the patient was draped in the appropriate gowning and accompanied to the operative area.  following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  when the patient and i were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome i desired.,thoracic spine: , with the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  the first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  with the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  the elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  the procedure was completed at the level of ti-ti2.  cavitation was achieved.,lumbar spine/sacro-iliac joints:,  with the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  linear force was used to increase the hip flexion gradually during this maneuver.  simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  the primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  this was repeated with the opposite lower extremity.  following this, a patrick-fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,with the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  the lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  this procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  these procedures were then repeated on the opposite lower extremity.,by approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance",26
"exam:,1.  diagnostic cerebral angiogram.,2.  transcatheter infusion of papaverine.,anesthesia: , general anesthesia,fluoro time: , 19.5 minutes,contrast:,  visipaque-270, 100 ml,indications for procedure: , the patient is a 13-year-old boy who had clipping for a left ica bifurcation aneurysm.  he was referred for a routine postop check angiogram.  he is doing fine clinically.  all questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,technique: , after informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  patient was placed under general anesthesia for entire duration of the procedure.  groin access was obtained with a stiff micropuncture wire and a 4-french sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  a 4-french angled glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  the catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  the images showed spasm of the left internal carotid artery and the left a1, it was thought planned to infused papaverine into the ica and the left a1.  after that the diagnostic catheter was taken up into the distal internal carotid artery.  sl-10 microcatheter was then prepped and was taken up with the support of transcend platinum micro guide wire.  the microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the a1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left a1.  the catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  patient was then transferred back to the icu in the children's hospital where he was extubated without any deficits.,interpretation of images:,1.  left common/internal carotid artery injections:  the left internal carotid artery is of normal caliber.  in the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left a1.  there is poor filling of the a2 through left internal carotid artery injection.  there is opacification of the ophthalmic and the posterior communicating artery mca along with the distal branches are filling normally.  capillary filling and venous drainage in mca distribution is normal and it is very slow in the aca distribution,2.  right internal carotid artery injection:  the right internal carotid artery is of normal caliber.  there is opacification of the right ophthalmic and the posterior communicating artery.  the right aca a1 is supplying bilateral a2 and there is no spasm of the distal anterior cerebral artery.  right mca along with the distal branches are filling normally.  capillary filling and venous drainage are normal.,3.  post-papaverine injection:  the post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  of note the previously clipped internal carotid ica bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,impression:,1.  well clipped left ica bifurcation aneurysm.,2.  moderately severe spasm of the internal carotid artery and left a1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.",21
"preoperative diagnoses:  ,1.  large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2.  cervical spondylosis.,3.  cervical stenosis, c5-c6 secondary to above (723.0).,postoperative diagnoses:  ,1.  large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2.  cervical spondylosis.,3.  cervical stenosis, c5-c6 secondary to above (723.0), with surgical findings confirmed.,procedures: , ,1.  anterior cervical discectomy at c5-c6 with spinal cord and spinal canal decompression (63075).,2.  anterior interbody fusion at c5-c6, (22554) utilizing bengal cage (22851).,3.  anterior instrumentation for stabilization by uniplate construction, c5-c6, (22845); with intraoperative x-ray times two.,anesthesia: , general.,service: , neurosurgery.,operation:  ,the patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  then the anterior aspect of the neck was prepped and draped in a 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 only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  a prominent anterior osteophyte at c5-c6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  this allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to pathology for a permanent section.  residual osteophytes and disc fragments were removed with 1 and 2-mm micro kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  a hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  at no time during the case was evidence of csf leakage, and hemostasis was readily achieved with pledgets of gelfoam subsequently removed with copious amounts of antibiotic irrigation.  once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  further stability was added nonetheless with an appropriate size uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  the wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 vicryl, and the skin with a subcuticular stitch of 4-0 vicryl, and this was steri-stripped for reinforcement, and a sterile dressing was applied, incorporating a penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,at the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",22
"preoperative diagnoses:,1.  ventilator-dependent respiratory failure.,2.  multiple strokes.,postoperative diagnoses:,1.  ventilator-dependent respiratory failure.,2.  multiple strokes.,procedures performed:,1.  tracheostomy.,2.  thyroid isthmusectomy.,anesthesia: , general endotracheal tube.,blood loss: , minimal, less than 25 cc.,indications:,  the patient is a 50-year-old gentleman who presented to the emergency department who had had multiple massive strokes.  he had required ventilator assistance and was transported to the icu setting.  because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,procedure: , after all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  the patient was brought to the operative suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  the neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  the skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  the patient was prepped and draped in usual fashion.  the surgeons were gowned and gloved.  a vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  at this point, the midline raphe was identified and the strap muscles were separated utilizing the bovie cautery.  once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  a high-riding innominate was not identified.  at this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with bovie cautery.  suture ligation with #3-0 vicryl was then performed on the thyroid gland in a double interlocking fashion.  this cleared a significant portion of the trachea.  the overlying pretracheal fascia was then cleared with use of pressured forceps as well as bovie cautery.  now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  the second tracheal ring was identified.  the bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  at this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  the airway was entered and inferior to the base, window was created.  the anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  at this point, a #8 shiley tracheostomy tube was inserted freely into the tracheal lumen.  the balloon was inflated and the ventilator was attached.  he was immediately noted to have return of the co2 waveform and was ventilating appropriately according to the anesthetist.  now, all surgical retractors were removed.  the baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  the tube was further secured around the patient's neck with iv tubing.  finally, a drain sponge was placed.  at this point, procedure was felt to be complete.  the patient was returned to the icu setting in stable condition where a chest x-ray is pending.",37
"dobutamine stress echocardiogram,reason for exam: , chest discomfort, evaluation for coronary artery disease.,procedure in detail: , the patient was brought to the cardiac center.  cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  the patient maximized at 30 mcg/kg per minute.  images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,wall motion assessed at all levels as well as at recovery.,the patient got nauseated, had some mild shortness of breath.  no angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,the resting heart rate was 78 with the resting blood pressure 186/98.  heart rate reduced by the vasodilator effects of dobutamine to 130/80.  maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,the ekg at rest showed sinus rhythm with no st-t wave depression suggestive of ischemia or injury.  incomplete right bundle-branch block was seen.  the maximal stress test ekg showed sinus tachycardia.  there was subtle upsloping st depression in iii and avf, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no st elevation seen.,no ventricular tachycardia or ventricular ectopy seen during the test.  the heart rate recovered in a normal fashion after using metoprolol 5 mg.,the heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,the ef at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  all walls mentioned were augmented in a normal fashion.  at maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  ef improved to about 70%.,the wall motion score was unchanged.,impression:,1.  maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  negative ekg criteria for ischemia.,3.  normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  this is considered the negative dobutamine stress echocardiogram test, medical management.",3
"procedure: , esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,indications for procedure: , a 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  currently, he has a fistula from his anterior abdominal wall out.  it does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  ct scans show thickened terminal ileum, which suggest that we are dealing with crohn's disease.  endoscopy is being done to evaluate for crohn's disease.,medications:  ,general anesthesia.,instrument:,  olympus gif-160 and pcf-160.,complications: , none.,estimated blood loss:,  less than 5 ml.,findings: , with the patient in the supine position, intubated under general anesthesia.  the endoscope was inserted without difficulty into the hypopharynx.  the scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  lower esophageal sphincter was located at 40 cm from the central incisors.  it appeared normal and appeared to function normally.  the endoscope was advanced into the stomach, which was distended with excess air.  rugal folds were flattened completely.  there were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with crohn's involvement of the stomach.  the endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  two additional biopsies were obtained in the antrum for clo testing.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated that part of the procedure well.,the patient was turned and scope was changed for colonoscopy.  prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  the colonoscope was then inserted into the anal verge.  the colonic clean out was excellent.  the scope was advanced without difficulty to the cecum.  the cecal area had multiple ulcers with exudate.  the ileocecal valve was markedly distorted.  biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  the colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  no fistulas were noted in the colon.  excess air was evacuated from the colon.  the scope was removed.  the patient tolerated the procedure well and was taken to recovery in satisfactory condition.,impression: , normal esophagus and duodenum.  there were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  all these findings are consistent with crohn's disease.,plan:  ,begin prednisone 30 mg p.o. daily.  await ppd results and chest x-ray results, as well as cocci serology results.  if these are normal, then we would recommend remicade 5 mg/kg iv infusion.  we would start modulon 50 ml/h for 20 hours to reverse the malnutrition state of this boy.  check cmp and phosphate every monday, wednesday, and friday for receding syndrome noted by following potassium and phosphate.  we will discuss with dr. x possibly repeating the ct fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  he will need an upper gi to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  if he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with crohn's in the small intestine that we cannot visualize with endoscopy.",14
"preoperative diagnosis: , breast mass, left.,postoperative diagnosis:,  breast mass, left.,procedure:,  excision of left breast mass.,operation: , after obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia.  the time-out process was followed.  preoperative antibiotic was given.  the patient was prepped and draped in the usual fashion.  the mass was identified adjacent to the left nipple.  it was freely mobile and it did not seem to hold the skin.  an elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia.  the whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc.  hemostasis was achieved with the cautery.  the specimen was sent to pathology and the tissues were closed in layers including a subcuticular suture of monocryl.  a small pressure dressing was applied.,estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.",23
"history:  ,this 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  no confirmed prior history of heart attack, myocardial infarction, heart failure.  history dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  the blood pressure was up transiently last summer when this seemed to start and she was asked not to take claritin-d, which she was taking for what she presumed was allergies.  she never had treated hypertension.  she said the blood pressure came down.  she is obviously very hypertensive this evening.  she has some mid scapular chest discomfort.  she has not had chest pain, however, during any of the other previous symptoms and spells.,cardiac risks:,  does not smoke, lipids unknown.  again, no blood pressure elevation, and she is not diabetic.,family history:,  negative for coronary disease.  dad died of lung cancer.,drug sensitivities:,  penicillin.,current medications: , none.,surgical history:,  cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,systems review: , did not get headaches or blurred vision.  did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  no reflux, abdominal distress.  no other types of indigestion, gi bleed.  gu:  negative.  she is unaware of any kidney disease.  did not have arthritis or gout.  no back pain or surgical joint treatment.  did not have claudication, carotid disease, tia.  all other systems are negative.,physical findings,vital signs:  presenting blood pressure was 170/120 and her pulse at that time was 137.  temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  saturation of 86%.  currently, blood pressure 120/70, heart rate is down to 100.,eyes:  no icterus or arcus.,dental:  good repair.,neck:  neck veins, cannot see jvd, at this point, carotids, no bruits, carotid pulse brisk.,lungs:  fine and coarse rales, lower two thirds of chest.,heart:  diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  there is loud third heart sound.  no murmur.,abdomen:  overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,skeletal:  no acute joints.,extremities:  good pulses.  no edema.,neurologically:  no focal weakness.,mental status:  clear.,diagnostic data: , 12-lead ecg, left bundle-branch block.,laboratory data:,  all pending.,radiographic data: , chest x-ray, pulmonary edema, cardiomegaly.,impression,1.  acute pulmonary edema.,2.  physical findings of dilated left ventricle.,3.  left bundle-branch block.,4.  breast cancer in 1992.,plan:  ,admit.  aggressive heart failure management.  get echo.  start ace and coreg.  diuresis of course underway.",5
"title of operation: , right suboccipital craniectomy for resection of tumor using the microscope modifier 22 and cranioplasty.,indication for surgery: , the patient with a large 3.5 cm acoustic neuroma.  the patient is having surgery for resection.  there was significant cerebellar peduncle compression.  the tumor was very difficult due to its size as well as its adherence to the brainstem and the nerve complex.  the case took 12 hours.  this was more difficult and took longer than the usual acoustic neuroma.,preop diagnosis: , right acoustic neuroma.,postop diagnosis: , right acoustic neuroma.,procedure:,  the patient was brought to the operating room.  general anesthesia was induced in the usual fashion.  after appropriate lines were placed, the patient was placed in mayfield 3-point head fixation, hold into a right park bench position to expose the right suboccipital area.  a time-out was settled with nursing and anesthesia, and the head was shaved, prescrubbed with chlorhexidine, prepped and draped in the usual fashion.  the incision was made and cautery was used to expose the suboccipital bone.  once the suboccipital bone was exposed under the foramen magnum, the high speed drill was used to thin out the suboccipital bone and the craniectomy carried out with leksell and insertion with kerrison punches down to the rim of the foramen magnum as well as laterally to the edge of the sigmoid sinus and superiorly to the edge of the transverse sinus.  the dura was then opened in a cruciate fashion, the cisterna magna was drained, which nicely relaxed the cerebellum.  the dura leaves were held back with the 4-0 nurolon.  the microscope was then brought into the field, and under the microscope, the cerebellar hemisphere was elevated.  laterally, the arachnoid was very thick.  this was opened with bipolar and microscissors and this allowed for the cerebellum to be further mobilized until the tumor was identified.  the tumor was quite large and filled up the entire lateral aspect of the right posterior fossa.  initially two retractors were used, one on the tentorium and one inferiorly.  the arachnoid was taken down off the tumor.  there were multiple blood vessels on the surface, which were bipolared.  the tumor surface was then opened with microscissors and the cavitron was used to began debulking the lesion.  this was a very difficult resection due to the extreme stickiness and adherence to the cerebellar peduncle and the lateral cerebellum; however, as the tumor was able to be debulked, the edge began to be mobilized.  the redundant capsule was bipolared and cut out to get further access to the center of the tumor.  working inferiorly and then superiorly, the tumor was taken down off the tentorium as well as out the 9th, 10th or 11th nerve complex.  it was very difficult to identify the 7th nerve complex.  the brainstem was identified above the complex.  similarly, inferiorly the brainstem was able to be identified and cotton balls were placed to maintain this plain.  attention was then taken to try identify the 7th nerve complex.  there were multitude of veins including the lateral pontine vein, which were coming right into this area.  the lateral pontine vein was maintained.  microscissors and bipolar were used to develop the plain, and then working inferiorly, the 7th nerve was identified coming off the brainstem.  a number 1 and number 2 microinstruments were then used to began to develop the plane.  this then allowed for the further appropriate plane medially to be identified and cotton balls were then placed.  a number 11 and number 1 microinstrument continued to be used to free up the tumor from the widely spread out 7th nerve.  cavitron was used to debulk the lesion and then further dissection was carried out.  the nerve stimulated beautifully at the brainstem level throughout this.  the tumor continued to be mobilized off the lateral pontine vein until it was completely off.  the cavitron was used to debulk the lesion out back laterally towards the area of the porus.  the tumor was debulked and the capsule continued to be separated with number 11microinstrument as well as the number 1 microinstrument to roll the tumor laterally up towards the porus.  at this point, the capsule was so redundant, it was felt to isolate the nerve in the porus.  there was minimal bulk remaining intracranially.  all the cotton balls were removed and the nerve again stimulated beautifully at the brainstem.  dr. x then came in and scrubbed into the case to drill out the porus and remove the piece of the tumor that was left in the porus and coming out of the porus.,i then scrubbed back into case once dr. x had completed removing this portion of the tumor.  there was no tumor remaining at this point.  i placed some norian in the porus to seal any air cells, although there were no palpated.  an intradural space was then irrigated thoroughly.  there was no bleeding.  the nerve was attempted to be stimulated at the brainstem level, but it did not stimulate at this time.  the dura was then closed with 4-0 nurolons in interrupted fashion.  a muscle plug was used over one area.  duragen was laid and strips over the suture line followed by hemaseel.  gelfoam was set over this and then a titanium cranioplasty was carried out.  the wound was then irrigated thoroughly.  o vicryls were used to close the deep muscle and fascia, 3-0 vicryl for subcutaneous tissue, and 3-0 nylon on the skin.,the patient was extubated and taken to the icu in stable condition.",22
"subjective:,  the patient comes back to see me today.  she is a pleasant 73-year-old caucasian female who had seen dr. xyz with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  dr. xyz had performed right and left facet and sacroiliac joint injections, subsequent right l3 to s1 medial branch blocks and radiofrequency ablation on the right from l3 to s1.  she was subsequently seen with some mid back pain and she had right t8-t9 and t9-t10 facet injections on 10/28/2004.  she was last seen on 04/08/2005 with recurrent pain in her low back on the right.  dr. xyz repeated her radiofrequency ablation on the right side from l3-s1 on 05/04/2005.,the patient comes back to see me today.  she states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  she is also complaining of pain in both knees.  she says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  she has not had any x-rays for quite some time.  she is taking some lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  she is also taking celebrex through dr. s’ office.,past medical history:,  essentially unchanged from my visit of 04/08/2005.,physical examination:,general:  reveals a pleasant caucasian female.,vital signs:  height is 5 feet 5 inches.  weight is 183 pounds.  she is afebrile.,heent:  benign.,neck:  shows functional range of movements with a negative spurling's.,musculoskeletal:  examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  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 decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  she has no other 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.  sensation is intact to pinprick.,functional examination:,  gait has a normal stance and swing phase with no antalgic component to it.,impression:,1.  low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right l4-5 and l5-s1.,2.  improved, spinal right l3-s1 radiofrequency ablation.,3.  right sacroiliac joint sprain/strain, symptomatic.,4.  left lumbar facet joint syndrome, stable.,6.  right thoracic facet joint syndrome, stable.,7.  lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  degenerative disc disease of both knees, symptomatic.,9.  pes anserinus bursitis, bilaterally symptomatic.,10.  chronic pain syndrome.,recommendations:,  dr. xyz and i discussed with the patient her pathology.  she has some symptoms in her low back on the right side at the sacroiliac joint.  dr. xyz will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  she is also having pain in both knees.  we will plan on x-rays of both knees, ap and lateral, and plan on seeing her back on monday or friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  i explained the rationale for each of these injections, possible complications and she wishes to proceed.  in the interim, she can continue on lortab and celebrex.  we will plan for the follow up following these interventions, sooner if needed.  she voiced understanding and agreement.  physical exam findings, history of present illness, and recommendations were performed with and in agreement with dr. goel's findings.",5
"patient was informed by dr. abc that he does not need sleep study as per patient.,physical examination:,general:  pleasant, brighter.,vital signs:  117/78, 12, 56.,abdomen:  soft, nontender.  bowel sounds normal.,assessment and plan:,1.  constipation.  milk of magnesia 30 ml daily p.r.n., dulcolax suppository twice a week p.r.n.,2.  cad/angina.  see cardiologist this afternoon.,call me if constipation not resolved by a.m., consider a fleet enema then as discussed.,",14
"chief complaint:, coughing up blood and severe joint pain.,history of present illness:,  the patient is a 37 year old african american woman with history of chronic allergic rhinitis who presents to an outpatient clinic with severe pain in multiple joints and hemoptysis for 1 day. the patient was at her baseline state of health until 2 months prior to admission when her usual symptoms of allergic rhinitis worsened. in addition to increased nasal congestion and drainage, she also began having generalized fatigue, malaise, and migratory arthralgias involving bilateral wrists, shoulders, elbows, knees, ankles, and finger joints. she also had intermittent episodes of swollen fingers that prevented her from making a fist. patient denied recent flu-like illness, fever, chills, myalgias, or night sweats. four weeks after the onset of arthralgias patient developed severe bilateral eye dryness and redness without any discharge. she was evaluated by an ophthalmologist and diagnosed with conjunctivitis. she was given eye drops that did not relieve her eye symptoms. two weeks prior to admission patient noted the onset of rust colored urine. no bright red blood or clots in the urine. she denied having dysuria, decreased urine output, abdominal pain, flank pain, or nausea/vomiting. patient went to a community er, and had a ct scan of the abdomen that was negative for kidney stones. she was discharged from the er with bactrim for possible uti. during the next week patient had progressively worsening arthralgias to the point where she could hardly walk. on the day of admission, she developed a cough productive of bright red blood associated with shortness of breath and nausea, but no chest pain or dizziness. this prompted the patient to go see her primary care physician. after being seen in clinic, she was transferred to st. luke’s episcopal hospital for further evaluation.,past medical history:, allergic rhinitis, which she has had for many years and treated with numerous medications. no history of diabetes, hypertension, or renal disease. no history tuberculosis, asthma, or upper airway disease.,past surgical history:, appendectomy at age 21. c-section 8 years ago.,ob/gyn: g2p2; last menstrual period 3 weeks ago. heavy menses due to fibroids.,social history:, patient is married and lives with her husband and 2 children. works in a business office. denies any tobacco, alcohol, or illicit drug use of any kind. no history of sexually transmitted diseases. denies exposures to asbestos, chemicals, or industrial gases. no recent travel. no recent sick contacts.,family history:, mother and 2 maternal aunts with asthma. no history of renal or rheumatologic diseases.,medications:, allegra 180mg po qd, zyrtec 10mg po qd, claritin 10mg po qd,no herbal medication use.,allergies:, no known drug allergies.,review of systems:, no rashes, headache, photophobia, diplopia, or oral ulcers. no palpitations, orthopnea or pnd. no diarrhea, constipation, melena, bright red blood per rectum, or pale stool. no jaundice. decreased appetite, but no weight loss.,physical examination:,vs: t 100.2f bp 132/85 p 111 rr 20 o2 sat 95% on room air,gen: well-developed woman in no apparent distress.,skin: no rashes, nodules, ecchymoses, or petechiae.,lymph nodes: no cervical, axillary, or inguinal lymphadenopathy.,heent: pupils equally round and reactive to light. extra-ocular movements intact. anicteric sclerae. erythematous sclerae and pale conjunctivae. dry mucous membranes. no oropharyngeal lesions. bilateral tympanic membranes clear. no nasal deformities.,neck: supple. no increased jugular venous pressure. no thyromegaly.,chest: decreased breath sounds throughout bilateral lung fields with occasional diffuse crackles. no wheezes or rales.,cv: tachycardic. regular rhythm. no murmurs, gallops, or rubs.,abdomen: soft with normal active bowel sounds. non-distended and non-tender. no masses palpated. no hepatosplenomegaly.,rectal: brown stool. guaiac negative.,ext: no clubbing, cyanosis, or edema. 2+ pulses bilaterally. tenderness and mild swelling of bilateral wrists, mcps and pips with decreased range of motion and grip function. bilateral wrists warm without erythema. bilateral elbows, knees, and ankles tender to palpation with decreased range of motion, but no erythema, warmth, or swelling of these joints.,neuro: cranial nerves intact. 2+ dtrs bilaterally and symmetrically. motor strength and sensation are within normal limits.,studies:,chest x-ray (10/03):,suboptimal inspiratory effort. no evidence of pneumonic consolidation, pleural effusion, pneumothorax, or pulmonary edema. cardiomediastinal silhouette is unremarkable.,ct scan of chest (10/03):,prominence of the bronchovascular markings bilaterally with a nodular configuration. there are mixed ground glass interstitial pulmonary infiltrates throughout both lungs with a perihilar predominance. aortic arch is of normal caliber. the pulmonary arteries are of normal caliber. there is right paratracheal lymphadenopathy. there is probable bilateral hilar lymphadenopathy. trachea and main stem bronchi are normal. the heart is of normal size.,renal biopsy:,microscopic description : ten glomeruli are present. there are crescents in eight of the glomeruli. some of the glomeruli show focal areas of apparent necrosis with fibrin formation. the interstitium consists of a fairly dense infiltrate of lymphocytes, plasma cells with admixed eosinophils. the tubules for the most part are unremarkable. no vasculitis is identified.,immunofluorescence description : there are no staining for igg, iga, igm, c3, kappa, lambda, c1q, or albumin.,electron microscopic description : mild to moderate glomerular, tubular, and interstitial changes. mesangium has multifocal areas with increased matrix and cells. there is focal mesangial interpositioning with the filtration membrane. interstitium has multifocal areas with increased collagen. there are focal areas with interstitial aggregate of fibrin. within the collagen substrate are infiltrates of lymphocytes, plasma cells, eosinophils, and macrophages. the glomerular sections evaluated show no electron-dense deposits in the filtration membrane or mesangium.,microscopic diagnosis: pauci-immune crescentic glomerulonephritis with eosinophilic interstitial infiltrate.",15
"procedures:,  esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,reason for procedure: , child with abdominal pain and rectal bleeding.  rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,consent:,  history and physical examination was performed.  the procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  opportunity for questions was provided and informed consent was obtained.,medication:  ,general anesthesia.,instrument: , olympus gif-160.,complications:,  none.,findings: , with the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  the esophageal mucosa and vascular pattern appeared normal.  the lower esophageal sphincter was located at 25 cm from the central incisors.  it appeared normal.  a z-line was identified within the lower esophageal sphincter.  the endoscope was advanced into the stomach, which distended with excess air.  rugal folds flattened completely.  gastric mucosa appeared normal throughout.  no hiatal hernia was noted.  pyloric valve appeared normal.  the endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  additional 2 biopsies were obtained for clo testing in the antrum.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated that part of procedure well.  the patient was turned and the scope was advanced with some difficulty to the terminal ileum.  the terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  the polyp was severed.  there was no bleeding at the stalk after removal of the polyp head.  the polyp head was removed by suction.  excess air was evacuated from the colon.  the patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  estimated blood loss approximately 5 ml.,impression: , normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,plan:  ,histologic evaluation and clo testing.  i will contact the parents next week with biopsy results and further management plans will be discussed at that time.",14
"reason for admission: , sepsis.,history of present illness:  ,the patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  in the emergency room, the patient was found to have a ct scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  the patient is unable to provide further history.  the patient's son is at the bedside and confirmed his history.  the patient was given iv antibiotics in the emergency room.  he was also given some hydration.,past medical history:,1.  history of cad.,2.  history of dementia.,3.  history of cva.,4.  history of nephrolithiasis.,allergies: , none.,medications:,1.  ambien.,2.  milk of magnesia.,3.  tylenol.,4.  tramadol.,5.  soma.,6.  coumadin.,7.  zoloft.,8.  allopurinol.,9.  digoxin.,10.  namenda.,11.  zocor.,12.  buspar.,13.  detrol.,14.  coreg.,15.  colace.,16.  calcium.,17.  zantac.,18.  lasix.,19.  seroquel.,20.  aldactone.,21.  amoxicillin.,family history:  ,noncontributory.,social history: , the patient lives in a board and care.  no tobacco, alcohol or iv drug use.,review of systems: , as per the history of present illness, otherwise unremarkable.,physical examination:,vital signs:  the patient is currently afebrile.  pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,general:  the patient is awake.  not oriented x3, in no acute distress.,heent:  pupils are equal, round, and reactive to light and accommodation.  extraocular movements are intact.  mucous membranes are dry.,neck:  supple.  no thyromegaly.  no jugular venous distention.,heart:  irregularly irregular, brady.,lungs:  clear to auscultation bilaterally anteriorly.,abdomen:  positive normoactive bowel sounds.  soft.  tenderness in the suprapubic region without rebound.,extremities:  no clubbing, cyanosis or edema in upper and lower extremities.",5
"preoperative diagnoses:  ,1.  posttraumatic nasal deformity.,2.  nasal obstruction.,3.  nasal valve collapse.,4.  request for cosmetic change with excellent appearance of nose.,postoperative diagnoses:,1.  posttraumatic nasal deformity.,2.  nasal obstruction.,3.  nasal valve collapse.,4.  request for cosmetic change with excellent appearance of nose.,operative procedures:,1.  left ear cartilage graft.,2.  repair of nasal vestibular stenosis using an ear cartilage graft.,3.  cosmetic rhinoplasty.,4.  left inferior turbinectomy.,anesthesia: , general via endotracheal tube.,indications for operation: , the patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  we discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  the patient had questions asked and answered.  informed consent was obtained.,procedure in detail: , the patient was taken to the operating room and placed in supine position.  the appropriate level of general endotracheal anesthesia was induced.  the patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  the septal angle was approached and submucoperichondrial flaps were elevated.  severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  the upper laterals were divided and medial and lateral osteotomies were carried out.  inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  the two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  it was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  the upper lateral cartilage was noted to be of the same width and length in size.  yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  the upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  the scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  a middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  the spreader brought an excellent aesthetic appearance to the nose.  we left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  mucoperichondrial flaps were closed with 4-0 plain gut suture.  the skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a denver splint was applied.  the patient was awakened in the operating room and taken to the recovery room in good condition.",37
"preoperative diagnosis: , desires permanent sterilization.,postoperative diagnosis: , desires permanent sterilization.,procedure performed: , laparoscopic bilateral tubal occlusion with hulka clips.,anesthesia: , general.,estimated blood loss: , less than 20 cc.,complications:  ,none.,findings: , on bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  there were no adnexal masses appreciated.  the vulva and perineum appeared normal.  laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  there was a functional cyst on the left ovary.  there was filmy adhesion in the left pelvic sidewall.  there were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  the uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  the liver was visualized and appeared normal.  the spleen was also visualized.,indications: , this patient is a 34-year-old gravida 4, para-4-0-0-4 caucasian female who desires permanent sterilization.  she recently had a spontaneous vaginal delivery in june and her family planning is complete.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  she was then prepped and draped and placed in the dorsal lithotomy position.  a bimanual exam was performed and the above findings were noted.  prior to beginning the procedure, her bladder was drained with a red robinson catheter.  a weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  the cervix was dilated so that the uterine elevator could be placed.  gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  the veress needle was then inserted and using sterile saline ______ the pelvic cavity.  the abdomen was then insufflated with appropriate volume and flow of co2.  the #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  a second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  using the hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  a second hulka clip was then placed across the entire diameter just proximal to this.  there was good hemostasis at the fallopian tube.  the right fallopian tube was then identified and followed out to its fimbriated end and the hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  a second hulka clip was placed just distal to this again across the entire diameter.  good hemostasis was obtained.  at this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  the laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  the umbilical incision was then closed with two interrupted #4-0 undyed vicryl.  the suprapubic incision was then closed with steri-strips.  the uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  the patient tolerated that procedure well.  the sponge, lap, and needle counts were correct x2.  she will follow up postoperatively for followup care.",37
"subjective: , the patient is a 60-year-old female, who complained of coughing during meals.  her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  the patient had a history of hypertension and tia/stroke.  the patient denied history of heartburn and/or gastroesophageal reflux disorder.  a modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,objective: , modified barium swallow study was performed in the radiology suite in cooperation with dr. abc.  the patient was seated upright in a video imaging chair throughout this assessment.  to evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,assessment,oral stage:,  premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,pharyngeal stage: , no aspiration was observed during this evaluation.  penetration was noted with cup sips of thin liquid only.  trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  the patient's hyolaryngeal elevation and anterior movement are within functional limits.  epiglottic inversion is within functional limits.,cervical esophageal stage:  ,the patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,diagnostic impression:,  no aspiration was noted during this evaluation.  penetration with cup sips of thin liquid.  the patient did cough during this evaluation, but that was noted related to aspiration or penetration.,prognostic impression: ,based on this evaluation, the prognosis for swallowing and safety is good.,plan: , based on this evaluation and following recommendations are being made:,1.  the patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  the patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  the patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,the patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.",36
"preoperative diagnoses:,1.  ta grade iii tis transitional cell carcinoma of the urinary bladder.,2.  lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  inability to pass a foley catheter x3.,postoperative diagnoses:,1.  ta grade iii tis transitional cell carcinoma of the urinary bladder.,2.  lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  inability to pass a foley catheter x3.,procedures:,1.  cystoscopy.,2.  transurethral resection of the prostate (turp).,anesthesia: , general laryngeal mask.,indications: , this patient is a 61-year-old white male who has been treated at the va in houston for a bladder cancer.  his history dates back to 2003 when he had a non-muscle invasive bladder cancer.  he had multiple cystoscopies and followups since that time with no evidence of recurrence.  however, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a ta grade iii transitional cell carcinoma associated with carcinoma in situ.  retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  i had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  we elected to allow his bladder to recover before starting the bcg.  we were ready to do that last week but two doctors and a nurse including myself were unable to pass foley catheter.  i repeated a cystoscopy in the office with findings of a high bladder neck and bph.  after a lengthy discussion with the patient and his wife, we elected to proceed with turp after a full informed consent.,findings: , at cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  there were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,procedure in detail: , the patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  a cystourethroscopy was performed with a #23 french acmi panendoscope and 70-degree lens with the findings as described.  we removed the cystoscope and passed a #28 french continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 french with van buren sounds.  inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  the groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  hemostasis was achieved, and then a similar procedure performed in the right side.  we resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  chips were removed with ellik evacuator.  there was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  a #24 french three-way foley catheter was placed with efflux of clear irrigant.  the patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.",37
"procedure: , endoscopy.,clinical indications: , intermittent rectal bleeding with abdominal pain.,anesthesia: , fentanyl 100 mcg and 5 mg of iv versed.,procedure:,  the patient was taken to the gi lab and placed in the left lateral supine position.  continuous pulse oximetry and blood pressure monitoring were in place.  after informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  with swallowing, the scope was advanced down the esophagus into the body of the stomach.  the scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  it appeared free of stricture, neoplasm, or ulceration.  samples were obtained from the antrum and prepyloric area to check for helicobacter, rapid urease, and additional samples were sent to pathology.  retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  the scope was then slowly removed.  the distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  the remaining portion of the esophagus was normal.,impression:,  abdominal pain.  symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,recommendations:,  await results of clo testing and biopsies.  return to clinic with dr. spencer in 2 weeks for further discussion.",14
"reason for visit: , the patient is a 74-year-old woman who presents for neurological consultation referred by dr. x.  she is accompanied to the appointment by her husband and together they give her history.,history of present illness: , the patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  danish is her native language, but she has been in the united states for many many years and speaks fluent english, as does her husband.,with respect to her walking and balance, she states ""i think i walk funny.""  her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  she has difficulty stepping up on to things like a scale because of this imbalance.  she does not festinate.  her husband has noticed some slowing of her speed.  she does not need to use an assistive device.  she has occasional difficulty getting in and out of a car.  recently she has had more frequent falls.  in march of 2007, she fell when she was walking to the bedroom and broke her wrist.  since that time, she has not had any emergency room trips, but she has had other falls.,with respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,the patient does not have headaches.,with respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, ""i do not feel as smart as i used to be.""  she feels that her thinking has slowed down.  her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,the patient has not had trouble with syncope.  she has had past episodes of vertigo, but not recently.,past medical history:  ,significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  she has been on ambien, which is no longer been helpful.  she has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,family history: , her father died with heart disease in his 60s and her mother died of colon cancer.  she has a sister who she believes is probably healthy.  she has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  she has two normal vaginal deliveries.,social history:  ,she lives with her husband.  she is a nonsmoker and no history of drug or alcohol abuse.  she does drink two to three drinks daily.  she completed 12th grade.,allergies: , codeine and sulfa.,she has a living will and if unable to make decisions for herself, she would want her husband, vilheim to make decisions for her.,medications,:  premarin 0.625 mg p.o. q.o.d., aciphex 20 mg p.o. q. daily, toprol 50 mg p.o. q. daily, norvasc 5 mg p.o. q. daily, multivitamin, caltrate plus d, b-complex vitamins, calcium and magnesium, and vitamin c daily.,major findings: , on examination today, this is a pleasant and healthy appearing woman.,vital signs:  blood pressure 154/72, heart rate 87, and weight 153 pounds.  pain is 0/10.,head:  head is normocephalic and atraumatic.  head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,spine:  spine is straight and nontender.  spinous processes are easily palpable.  she has very mild kyphosis, but no scoliosis.,skin:  there are no neurocutaneous stigmata.,cardiovascular exam:  regular rate and rhythm.  no carotid bruits.  no edema.  no murmur.  peripheral pulses are good.  lungs are clear.,mental status:  assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  she scored 30/30 on the mmse when attention was tested with either spelling or calculations.  she had no difficulty with visual structures.,cranial nerves:  pupils are equal.  extraocular movements are intact.  face is symmetric.  tongue and palate are midline.  jaw muscles strong.  cough is normal.  scm and shrug 5 and 5.  visual fields intact.,motor exam:  normal for bulk, strength, and tone.  there was no drift or tremor.,sensory exam:  intact for pinprick and proprioception.,coordination:  normal for finger-to-nose.,reflexes:  are 2+ throughout.,gait:  assessed using the tinetti assessment tool.  she was fairly quick, but had some unsteadiness and a widened base.  she did not need an assistive device.  i gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,review of x-rays: , mri was reviewed from june 26, 2008.  it shows mild ventriculomegaly with a trace expansion into the temporal horns.  the frontal horn span at the level of foramen of munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  the sylvian aqueduct is patent.  there is no pulsation artifact.  her corpus callosum is bowed and effaced.  she has a couple of small t2 signal abnormalities, but no significant periventricular signal change.,assessment:  ,the patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,problems/diagnoses:,1.  possible adult hydrocephalus (331.5).,2.  mild gait impairment (781.2).,3.  mild cognitive slowing (290.0).,plan: , i had a long discussion with the patient her husband.,i think it is possible that the patient is developing symptomatic adult hydrocephalus.  at this point, her symptoms are fairly mild.  i explained to them the two methods of testing with csf drainage.  it is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and i described that test.  about 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  alternatively, i could bring her into the hospital for four days of csf drainage to determine whether she is likely to respond to shunt surgery.  this procedure carries a 2% to 3% risk of meningitis.  i also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.",5
"procedure performed:,1.  right femoral artery access.,2.  selective right and left coronary angiogram.,3.  left heart catheterization.,4.  left ventriculogram.,indications for procedure:,  a 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  the resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported lvef of 20% to 25%.  this was a sharp decline from a previous lvef of 50% to 55%.  we therefore, decided to proceed with coronary angiography.,technique: , after obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  the right groin was prepped and draped in the usual sterile manner.  2% lidocaine was used for infiltration anesthesia.  using modified seldinger technique, a 6-french sheath was introduced into the right femoral artery.  6-french jl4 and jr4 diagnostic catheters were used to perform the left and right coronary angiogram.  a 6-french pigtail catheter was used to perform the lv-gram in the rao projection.,hemodynamic data: , lvedp of 11.  there was no gradient across the aortic valve upon pullback.,angiographic findings:,1.  the left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  the left main coronary artery is free of any disease.,3.  the left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  the first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  the second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  one of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  the left anterior descending artery has a patent stent in the proximal lad.  the second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  there appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  the diagonal branches are free of any disease.,6.  the right coronary artery is a dominant vessel and has mild luminal irregularities.  its midsegment has a focal area of 30% narrowing as well.  the rest of the right coronary artery is free of any disease.,7.  the lv-gram performed in the rao projection shows well preserved left ventricular systolic function with an estimated lvef of 55%.,recommendation: , continue with optimum medical therapy.  because of the discrepancy between the left ventriculogram ef assessment and the echocardiographic ef assessment, i have discussed this matter with dr. xyz and we have decided to proceed with a repeat 2d echocardiogram.  the mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.",3
"exam:,1.  diagnostic cerebral angiogram.,2.  transcatheter infusion of papaverine.,anesthesia: , general anesthesia,fluoro time: , 19.5 minutes,contrast:,  visipaque-270, 100 ml,indications for procedure: , the patient is a 13-year-old boy who had clipping for a left ica bifurcation aneurysm.  he was referred for a routine postop check angiogram.  he is doing fine clinically.  all questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,technique: , after informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  patient was placed under general anesthesia for entire duration of the procedure.  groin access was obtained with a stiff micropuncture wire and a 4-french sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  a 4-french angled glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  the catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  the images showed spasm of the left internal carotid artery and the left a1, it was thought planned to infused papaverine into the ica and the left a1.  after that the diagnostic catheter was taken up into the distal internal carotid artery.  sl-10 microcatheter was then prepped and was taken up with the support of transcend platinum micro guide wire.  the microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the a1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left a1.  the catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  patient was then transferred back to the icu in the children's hospital where he was extubated without any deficits.,interpretation of images:,1.  left common/internal carotid artery injections:  the left internal carotid artery is of normal caliber.  in the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left a1.  there is poor filling of the a2 through left internal carotid artery injection.  there is opacification of the ophthalmic and the posterior communicating artery mca along with the distal branches are filling normally.  capillary filling and venous drainage in mca distribution is normal and it is very slow in the aca distribution,2.  right internal carotid artery injection:  the right internal carotid artery is of normal caliber.  there is opacification of the right ophthalmic and the posterior communicating artery.  the right aca a1 is supplying bilateral a2 and there is no spasm of the distal anterior cerebral artery.  right mca along with the distal branches are filling normally.  capillary filling and venous drainage are normal.,3.  post-papaverine injection:  the post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  of note the previously clipped internal carotid ica bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,impression:,1.  well clipped left ica bifurcation aneurysm.,2.  moderately severe spasm of the internal carotid artery and left a1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.",32
"indications:,  dysphagia.,premedication:,  topical cetacaine spray and versed iv.,procedure:,:  the scope was passed into the esophagus under direct vision.  the esophageal mucosa was all unremarkable.  there was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  the scope was passed on down into the stomach.  the gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  the scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  the scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  the scope was then withdrawn.,impression:,  normal upper gi endoscopy without any evidence of anatomical narrowing.",14
"preoperative diagnosis: , bilateral vesicoureteral reflux with right reflux nephropathy after deflux injection.,postoperative diagnosis: , bilateral vesicoureteral reflux with right reflux nephropathy after deflux injection.,procedure:,  cystoscopy under anesthesia, bilateral hit/sting with deflux under general anesthetic.,anesthesia: , general inhalational anesthetic.,fluids received: , 250 ml crystalloids.,estimated blood loss:,  less than 5 ml.,specimens:,  urine sent for culture.,abnormal findings:  ,gaping ureteral orifices, right greater than left, with deflux not in or near the ureteral orifices.  right ureteral orifice was hit with 1.5 ml of deflux and left with 1.2 ml of deflux.,history of present illness:  ,the patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction.  he has had a sting procedure performed but continues to have reflux bilaterally.  plan is for another injection.,description of operation:  ,the patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  once he was anesthetized, iv antibiotics were given.  he was then placed in a lithotomy position with adequate padding of his arms and legs.  his urethra was calibrated to 12-french with a bougie a boule.  a 9.5-french cystoscope was used and the offset system was then used.  his urethra was normal without valves or strictures.  his bladder was fairly normal with minimal trabeculations but no cystitis noted.  upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone.  this was similarly found on the left side where the deflux was not close to the orifice as well.  it was slightly more difficult because of the amount impacted upon our angle for injection.  we were able to ultimately get the deflux to go ahead with hit technique on the right into the ureter itself to inject a total of 1.5 ml to include the hit technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect.  once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding.  similar procedure was done on the left.  this was actually more difficult as the deflux injection from before displaced the ureter slightly more laterally but again hit technique was performed.  there was some mild bleeding and deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection.  at the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra.  the patient tolerated the procedure well and was in stable condition upon transfer to recovery.  a low-dose of iv toradol was given at the end of the procedure as well.",38
"preoperative diagnosis: , post infarct angina.,type of procedure: , left cardiac catheterization with selective right and left coronary angiography.,procedure: , after informed consent was obtained, the patient was brought to the cardiac catheterization laboratory, and the groin was prepped in the usual fashion.  using 1% lidocaine, the right groin was infiltrated, and using the seldinger technique, the right femoral artery was cannulated.  through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 french pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  pressure measurements were obtained and cineangiograms in the rao and lao positions were then obtained.  catheter was then withdrawn and a #6 french non-bleed-back sidearm sheath was then introduced, and through this, a 6 french judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  cineangiograms were obtained of the left coronary system.  this catheter was then exchanged for a judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  cineangiograms were obtained, and the catheter and sheath were then withdrawn.  the patient tolerated the procedure well and left the cardiac catheterization laboratory in stable condition.  no evidence of hematoma formation or active bleeding.  ,complications: , none.  ,total contrast: , 110 cc of hexabrix.  ,total fluoroscopy time:  ,1.8 minutes.  ,medications: , reglan 10 mg p.o., 5 mg p.o.  valium, benadryl 50 mg p.o. and heparin 3,000 units iv push.",3
"indications for procedure: , a 79-year-old filipino woman referred for colonoscopy secondary to heme-positive stools.  procedure done to rule out generalized diverticular change, colitis, and neoplasia.,description of procedure: , the patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  informed consent was signed by the patient.,with the patient in left decubitus position, had received a cumulative dose of 4 mg of versed and 75 mg of demerol, using olympus video colonoscope under direct visualization was advanced to the cecum.  photodocumentation of appendiceal orifice and the ileocecal valve obtained.  cecum was slightly obscured with stool but the colon itself was adequately prepped.  there was no evidence of overt colitis, telangiectasia, or overt neoplasia.  there was moderately severe diverticular change, which was present throughout the colon and photodocumented.  the rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  the patient tolerated the procedure well without any complications.,impression:,1.  colonoscopy to the cecum with adequate preparation.,2.  long tortuous spastic colon.,3.  moderately severe diverticular changes present throughout.,4.  mild internal hemorrhoids.,recommendations:,1.  clear liquid diet today.,2.  follow up with primary care physician as scheduled from time to time.,3.  increase fiber in diet, strongly consider fiber supplementation.",14
"concomitant chemoradiotherapy for curative intent patients,this patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  the chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  it has been shown in the literature that this will maximize the chance of control.,during the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  it is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  this combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  in accordance, this requires more frequency consultation and coordination with the medical oncologist.  therefore, this becomes a very time intensive treatment and justifies cpt code 77470.",16
"preoperative diagnosis:,  acute appendicitis.,postoperative diagnosis:,  ruptured appendicitis.,procedure:,  laparoscopic appendectomy.,indications for procedure:,  this patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  the patient has elevated white count on exam and ct scan consistent with acute appendicitis.,description of procedure: , the patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  the patient's abdomen was prepped and draped in usual sterile fashion.  a periumbilical incision was made.  the fascia was incised.  peritoneal cavity entered bluntly.  a 10-mm trocar and scope was passed.  peritoneal cavity was insufflated.  five-mm ports placed in left lower and hypogastric areas.  on visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  we proceeded to take the mesoappendix down to the base, and once the base was free, we placed gia stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  we irrigated and suctioned out the right lower and pelvic areas.  we then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 vicryl, all skin incisions with 5-0 monocryl, and dressed with steri-strips.  the patient was extubated in the operating table and taken back to recovery room.  the patient tolerated the procedure well.",37
"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.",8
"constitutional:,  normal; negative for fever, weight change, fatigue, or aching.,heent:,  eyes normal; negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  ears normal; negative for hearing or balance problems.  nose normal; negative for runny nose, sinus problems, or nosebleeds.  mouth normal; negative for dental problems, dentures, or bleeding gums.  throat normal; negative for hoarseness, difficulty swallowing, or sore throat.,cardiovascular:,  normal; negative for angina, previous mi, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,pulmonary: , normal; negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,gastrointestinal: , normal; negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,genitourinary:, normal female or male; negative for incontinence, uti, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,skin: , normal; negative for rashes, keratoses, skin cancers, or acne.,musculoskeletal: , normal; negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,neurologic: , normal; negative for blackouts, headaches, seizures, stroke, or dizziness.,psychiatric: , normal; negative for anxiety, depression, or phobias.,endocrine:,  normal; negative for diabetes, thyroid, or problems with cholesterol or hormones.,hematologic/lymphatic: , normal; negative for anemia, swollen glands, or blood disorders.,immunologic: , negative; negative for steroids, chemotherapy, or cancer.,vascular:,  normal; negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.",15
"history of present illness: ,the patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom.  at that time, he reports both legs gave away on him and he fell.  he reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him.  he was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal.,he was then well until the 3rd of july 2008 when his legs again gave way on him.  this was not preceded by lightheadedness.  he was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia.  he started using a walker from that time, prior to that he was able to walk approximately two miles per day.  he again had a fall in august of 2008 after his legs gave way.  again, there was no lightheadedness associated with this.  he was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this.  he did not, however, return to the pre-july baseline.  in october of 2008, after another fall, he was found to have pneumonia again and shingles.  he is currently in a chronic rehabilitation unit.  he cannot use a walker and uses a wheelchair for everything.  he states that his hands have been numb, involving all the fingers of both hands for the past three weeks.  he is also losing muscle bulk in his hands and has noticed some general weakness of his hands.  he does, however, note that strength in his hands has not been normal since july 2008, but it is clearly getting worse.  he has been aware of some fasciculations in his legs starting in august 2008, these are present both in the lower legs and the thighs.  he does not report any cramps, problems with swallowing or problems with breathing.  he reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder.  he has had some problems with blood pressure drops, and does feel presyncopal when he stands.  he also reports that he has no feeling in his feet, and that his feet feel like sponges.  this has been present for about nine months.  he has also lost joint position sense in his feet for approximately nine months.,past medical history:,1.  pneumonia.  he has had recurrent episodes of pneumonia, which started at approximately age 20.  these have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year.  he is usually treated with antibiotics and then discharged.  there is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia.,2.  he has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement.  the patient does not have any history of diabetes and does not report any other medical problems.  he has lost approximately 18 pounds in the past month.,3.  he had an appendectomy in the 1940s.,4.  he had an ankle resection in 1975.,social history:  ,the patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars.  he has not smoked for the past 27 years.  he hardly ever uses alcohol.  he is currently retired.,family history: , there is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases.  his aunt has a history of type ii diabetes.,current medications: , fludrocortisone 0.1 mg p.o. q.d., midodrine 5 mg p.o. q.i.d., cymbalta 30 mg p.o. per day, prilosec 20 mg p.o. per day, lortab 10 mg p.o. per day, amoxil 500 mg p.o. per day, vitamin b12 1000 mcg weekly, vitamin d 1000 units per day, metamucil p.r.n., enteric-coated aspirin once a day, colace 200 mg p.o. q.d., senokot three tablets p.o. p.r.n., reglan 10 mg p.o. q.6h., xanax 0.25 mg p.o. q.8h. p.r.n., ambien 5 mg p.o. q.h.s. p.r.n. and dilaudid 2 mg tablets p.o. q.3h. p.r.n., protonix 40 mg per day, and megace 400 mg per day.,allergies:,  he has no medication or food allergies.,review of systems:,  please see the health questionnaire and clinical notes from today.,general physical examination:,vital signs:  bp was 137/60, p was 89, and his weight could not be measured because he was in a wheelchair.  his pain score was 0.,appearance:  no acute distress.  he is pleasant and well-groomed.,heent:  atraumatic, normocephalic.  no carotid bruits appreciated.,lungs:  there were few coarse crackles in both lung bases.,cardiovascular:  revealed a normal first and second heart sound, with no third or fourth heart sound and no murmurs.  the pulse was regular and of normal volume.,abdomen:  soft with no masses and normal bowel sounds.  there were no carotid bruits.,extremities:  no contractures appreciated.,neurological exam:,mse:  his orientation, language, calculations, 100-7 tests were all normal.  there was atrophy and fasciculations in both the arms and legs.,cranial nerves:  cranial nerve examination was normal with the exception that there was some mild atrophy of his tongue and possible fasciculations.  his palatal movement was normal and gag reflex was normal.,motor:  strength was decreased in all muscle groups as follows:  deltoid 4/4, biceps 4+/4+, triceps 5/5, wrist extensors 4+/4+, finger extensors 4-/4-, finger flexors 4-/4-, interossei 4-/4-, hip flexors 4+/4+, hip extensors 4+/4+, knee extensors 4/4, and knee flexors 4/4.  foot dorsiflexion, plantar flexion, eversion, toe extension and toe flexion was all 0 to 1.  there was atrophy in both hands and general atrophy of the lower limb muscles.  the feet were both cold and showed dystrophic features.  fasciculations were present mainly in the hands.  there was evidence of dysmetria and past pointing in the left hand.,reflexes:  reflexes were 0 in all sites in the arms and legs.  the jaw reflex was 2+.  vibration was severely decreased at the elbow and wrist and was absent in the fingers.  vibration was absent in the toes and ankle bilaterally and was severely decreased at the knee.  joint position sense was absent in the toes and severely decreased in the fingers.  pin perception was absent in the feet and was decreased to the upper thighs.  pin was decreased or absent in the fingers and decreased above the elbows.  the same distribution of sensory loss was found with monofilament testing.,coordination:  coordination was barely normal in the right hand.  rapid alternating movements were decreased in the left hand greater than the right hand.  the patient was unable to stand and therefore gait, romberg's test and balance could not be assessed.,diagnostic studies: , previous diagnostic studies and patient reports.  there were extensive patient reports, all of which were reviewed.  a previous x-ray study of the lateral chest performed in october 2008 showed poor inspiration with basilar atelectasis and an infiltrate.  an x-ray of the cervical, thoracic and lumbar spine showed some evidence of lumbar spinal stenosis.  a cta of the neck with and without contrast performed in november 2008 showed minor stenosis in the left carotid, a mild hard and soft plaque in the right carotid with approximately 55% stenosis.  the posterior circulation showed a slightly dominant right vertebral artery with no stenosis.  there was no significant stenosis, but there was minor extracranial stenosis noted.  an mri of the brain with and without contrast performed in november 2008 showed no evidence of an acute infarct, major vascular occlusion, and no abnormal enhancement with gadolinium administration.  there was also no significant sinusitis or mastoiditis.  this was an essentially normal brain mri.  a cbc performed in january 2009 showed an elevated white cell count of 11.3, a low red cell count of 3.43, elevated mch of 32.4 and the rest of the study was normal.  an electrolyte study performed in january 2009 showed a sodium which was low at 127, a calcium which was low at 8.3, and a low protein of 5.2 and albumin of 3.1.  the glucose was 86.  tsh performed in january 2009 was 1.57, which is within the normal range.  vitamin b12 was greater than a 1000, which is normal and the folate was 18.2, which was normal.  a myocardial stress study performed in december 2008 showed normal myocardial perfusion with persantine cardiolite spect.  the ecg was non-diagnostic.  there was normal regional wall motion of the left ventricle.  the left ventricular ejection fraction was 68%, which is within the normal range for males.  a ct of the lumbar spine without contrast performed in december 2008 showed a broad-based disc bulge at l1-l2, l2-l3, l3-l4 and l4-l5.  at l5-s1, in addition to the broad-based disc bulge, there was also an osteophyte complex and evidence of flavum hypertrophy without canal stenosis.  there was severe bilateral neural foraminal stenosis at l5-s1 and moderate neural foraminal stenosis at l1-l4.  an echocardiogram was performed in november 2008 and showed mild left atrial enlargement, normal left ventricular systolic function, mild concentric left ventricular hypertrophy, scleral degenerative changes in the aortic and mitral apparatus, mild mitral regurgitation, mild tricuspid regurgitation and mild to moderate aortic regurgitation.,diagnostic impression:  ,the patient presents with a severe neuropathy with marked large fiber sensory as well as motor findings.  he is diffusely weak as well as atrophic in all muscle groups both in his upper and lower extremities, although he is disproportionately weak in his lower extremities.  his proprioceptive and vibratory loss is severe in both the distal upper and lower extremities, signifying that he either has a severe sensory neuropathy or has involvement of the dorsal root ganglia.  according to the history, which was carefully checked, the initial onset of these symptoms goes back one and a half years, although there has only been significant progression in his condition since july 2008.  as indicated below, further diagnostic studies including a detailed nerve conduction and emg test today showed evidence of a severe sensory, motor, and axonal neuropathy and in addition there was evidence of a diffuse polyradiculopathy.  there was no involvement of the tongue on emg.  the laboratory testing as indicated below failed to show a specific cause for the neuropathy.  we are still, however, waiting for the paraneoplastic antibodies, which were send out lab to the mayo clinic.  this type of very severe sensorimotor neuropathy with significant proprioceptive loss may be seen in several conditions including peripheral nerve vasculitis due to a variety of disorders such as sle, sjogren's, rheumatoid arthritis, and mixed connective tissue disease.  in addition, it may also be seen with certain toxins, particularly chemotherapeutic agents.  the patient did not receive any of these.  it may also be seen as part of a paraneoplastic syndrome.  although the patient does not have any specific clinical symptoms of a cancer, it is noted that he has had an 18-pound weight loss in the past month and does have a remote history of smoking.  we have requested that he obtain a ct of his chest, abdomen and pelvis while he is in acute rehabilitation.  the verbal reports of these possibly did not show any evidence of a cancer.  we did also request that he obtain a gallium scan to see if there was any evidence of an unsuspected neoplasm.  the patient did undergo a nerve and muscle biopsy, this was a radial nerve and biceps muscle biopsy from the left arm.  this showed evidence of severe axonal loss.  there was no evidence of a vasculitis.  the vessels did show some mild intimal changes that would be consistent with atherosclerosis.  there were a few perivascular changes; however, there was no clear evidence of a necrotizing vasculitis even on multiple sections.  the muscle biopsy showed severe muscle fiber atrophy, with evidence of fiber grouping.  again, there was no evidence of inflammation or vasculitis.  evaluation so far has also shown no evidence of an amyloid neuropathy, no evidence of a monoclonal gammopathy, of sarcoidosis, and again there is no past history of a significant toxin or infective cause for the neuropathy.  specifically, there is no history of hiv exposure.  we would await the results of the gallium scan and of the paraneoplastic antibodies to see if these are helpful in making a diagnosis.  at this point, because of the severity and the axonal nature of the neuropathy, there is no specific therapy that will reverse the course of the illness, unless we find a specific etiology that can be stopped or reversed.  i have discussed these issues at length with the patient and with his son.  we also addressed whether or not there might be a previously undiagnosed inherited neuropathy.  i think this is unlikely given the short history and the rapid progression of the disorder.,there is also no family history that we can detect a neuropathy, and the patient does not have the typical phenotype for a chronic inherited neuropathy such as charcot-marie-tooth disease type 2.  however, since i have only seen the patient on one occasion and do not know what his previous examination showed two years ago, i cannot be certain that there may not have been the presence of a neuropathy preceding this.,plan:,1.  nerve conduction and emg will be performed today.  the results were indicated above.,2.  the following laboratory studies were requested including electrolytes, cbc, thyroid function tests, b12, ana, c-reactive protein, complement, cryoglobulins, double-stranded dna antibodies, folate level, hemoglobin a1c, immunofixation electrophoresis, p-anca, c-anca, protein electrophoresis, rheumatoid factor, paraneoplastic antibody studies requested from the mayo clinic, b12.  these studies showed minor changes, which included a low sodium level of 129 as previously noted, a low creatinine of 0.74, low calcium of 8.6, low total protein of 5.7.  the b12 was greater than 2000.  the immunoelectrophoresis, ana, double-stranded dna, anca, hemoglobin a1c, folate, cryoglobulins, complement, c-reactive protein were all normal or negative.  the b12 level was greater than 2000.  liver function tests were normal.  the glucose was 90.  esr was 10.  hemoglobin a1c was 5.5.,3.  a left radial sensory and left biceps biopsy were requested and have been performed and interpreted as indicated above.,4.  ct of chest, abdomen and pelvis.,5.  whole body gallium scan for evidence of an underlying neoplasm.,6.  the patient will go to the rehabilitation facility for acute rehabilitation and training.,7.  we have not made any changes to his medication.  he does have some mild orthostatic changes; however, he is adequately controlled with midodrine at a dose of 2.5 mg three times a day as needed up to 5 mg four times a day.  usually, he uses a lower dose of 2.5 three times a day to 5 mg three times a day.,8.  followup will be as determined by the family.",21
"subjective:,  the patient is here for a follow-up.  the patient has a history of lupus, currently on plaquenil 200-mg b.i.d.  eye report was noted and appreciated.  the patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago.  she denied having any trauma.  she states that the pain is bothering her.  she denies having any fevers, chills, or any joint effusion or swelling at this point.  she noted also that there is some increase in her hair loss in the recent times.,objective:,  the patient is alert and oriented.  general physical exam is unremarkable.  musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion.  hand examination is unremarkable today.  the rest of the musculoskeletal exam is unremarkable.,assessment:,  epicondylitis, both elbows, possibly secondary to lupus flare-up.,plan:,  we will inject both elbows with 40-mg of kenalog mixed with 1 cc of lidocaine.  the posterior approach was chosen under sterile conditions.  the patient tolerated both procedures well.  i will obtain cbc and urinalysis today.  if the patient's pain does not improve, i will consider adding methotrexate to her therapy.,sample doctor m.d.",33
"chief complaint:,1.  extensive stage small cell lung cancer.,2.  chemotherapy with carboplatin and etoposide.,3.  left scapular pain status post ct scan of the thorax.,history of present illness: , the patient is a 67-year-old female with extensive stage small cell lung cancer.  she is currently receiving treatment with carboplatin and etoposide.  she completed her fifth cycle on 08/12/10.  she has had ongoing back pain and was sent for a ct scan of the thorax.  she comes into clinic today accompanied by her daughters to review the results.,current medications: , levothyroxine 88 mcg daily, soriatane 25 mg daily, timoptic 0.5% solution b.i.d., vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,allergies: , no known drug allergies.,review of systems:  ,the patient continues to have back pain some time she also take two pain pill.  she received platelet transfusion the other day and reported mild fever.  she denies any chills, night sweats, chest pain, or shortness of breath.  the rest of her review of systems is negative.,physical exam:,vitals:",16
"xyz, o.d.,re:  abc,dob:  mm/dd/yyyy,dear dr. xyz:,thank you for your referral of patient abc.  the patient was referred for evaluation of cataracts bilaterally.,on examination, the patient was seeing 20/40 in her right eye and 20/50 in the left eye.  extraocular muscles were intact, visual fields were full to confrontation ou, and applanations are 12 mmhg bilaterally.  there is no relative afferent pupillary defect.  on slit lamp examination, lids and lashes were within normal limits.  the conj is quiet.  the cornea shows 1+ guttata bilaterally.  the ac is deep and quiet and irises are within normal limits bilaterally.  there is a dense 3 to 4+ nuclear sclerotic cataract in each eye.  on dilated fundus examination, cup-to-disc ratio is 0.1 ou.  the vitreous, macula, vessels, and periphery all appear within normal limits.,impression:  it appears that ms. abc' visual decline is caused by bilateral cataracts.  she would benefit from having removed.  the patient also showed some mild guttata ou indicating possible early fuchs dystrophy.  the patient should do well with cataract surgery and i have recommended this and she agreed to proceed with the first eye here shortly.  i will keep you up to date of her progress and any new findings as we perform her surgery in each eye.,again, thank you for your kind referral of this kind lady and i will be in touch with you.,sincerely,,",19
"procedure: , left heart catheterization, left and right coronary angiography, left ventricular angiography, and intercoronary stenting of the right coronary artery.,procedure in detail:  ,the patient was brought to the catheterization laboratory.  after informed consent, he was medicated with versed and fentanyl.  the right groin was prepped and draped, and infiltrated with 2% xylocaine.  percutaneously, #6-french arterial sheath was placed.  selective native left and right coronary angiography was performed followed by left ventricular angiography.  the patient had a totally occluded right coronary.  we initially started with a jr4 guide.  we were able to a sport wire through the total occlusion and saw a very tight stenosis.  we were able to get a 30 x 13 mm power saver balloon into the stenosis and dilated.  we then attempted to put a 30 x 12 mm stent across the stenosis, but we had very little guide support, the guide kept coming out.  we then switched to an al1 guide and that too did not enable us to get anything to cross this lesion.  we finally had to go an al2 guide, we were concerned that this could cause some proximal dissection.  that guided seated, we did have initial difficulty getting the wire back across the stenosis, and we did see a little staining suggesting we did have some tearing from the guide tip.  the surgeons were put on notice in case we could not get this vessel open, but we were able to re-cross with a sport wire.  we then re-dilated the area of stenosis and with good guide support, we were able to get a 30 x 23 mm vision stent, where the lesion was and post-dilated it to 18 atmospheres.  routine angiography did show that the distal posterolateral branch seems to be occluded, whether this was from distal wire dissection or distal thrombosis was unclear, but we were able to re-wire that area and get a 25 x12 vision balloon and dilate the area and re-establish flow to the small segment.  we then came back because of the residual dissection proximal to the first stent and put a 30 x15 mm vision stent at 18 atmospheres.  final angiography showed resolution of the dissection.  we could see a little staining extrinsic to the stent.  no perforation and excellent flow.  during the intervention, we did give a bolus and drip of angiomax.  at the end of the procedure, we stopped the angiomax and gave 600 mg of plavix.  we did a right femoral angiogram; however, the angio-seal plug could not take, so we used manual pressure and a femostop.  we transported the patient to his room in stable condition.,angiographic data:,  left main coronary is normal.  left anterior descending artery has a fair amount of wall disease proximally about 50 to 60% stenosis of the lad before it bifurcates into diagonal.  the diagonal does appear to have about 50% osteal stenosis.  there is a lot of plaquing further down the diagonal, but good flow.  the rest of the lad looked good pass the proximal 60% stenosis and after the diagonal branch.  circumflex artery was nondominant vessel, consisting of an obtuse marginal vessel.  the first obtuse marginal had a long 50% narrowing and then the av groove branch was free of any disease.  some mild collaterals to the right were seen.  right coronary angiography revealed a total occlusion of the right coronary, just about 0.5 cm after its origin.  after we got a wire across the area of occlusion, we could see some thrombosis and a 99% stenosis just at the curve.  following the balloon angioplasty, we established good flow down the distal vessel.  we still had about residual 70% stenosis.  when we had to go back with the al2 guide, we could see a little bit of staining in the proximal portion of the vessel that we did not notice previously and we felt that the tip of the guide caused a little bit of intimal dissection.  we re-dilated and then deployed.  repeat angiography now did show some hang up off dye distally.  we never did have the wire that far down, so this was probably felt to be due to distal embolization of some thrombus.  after deploying the stent, we had total resolution of the original lesion.  we then directed our attention to the posterolateral branch, which the remainder of the vessel was patent giving off a large pda.  the posterolateral branch appeared to be occluded in its mid portion.  we got a wire through and dilated this.  we then came back and put a second stent in the proximal area of the right coronary proximal and abutting to the previous stent.  repeat angiography now showed no significant dissection, a little bit of contrast getting extrinsic to the stent probably in a little subintimal pouch, but this was excluded by the stent.  there were no filling defects in the stent and excellent flow.  the distal posterolateral branch did open up, although it was little under-filled and there may have been some mild residual disease there.,impression: , atherosclerotic heart disease with total occlusion of right coronary, successfully stented to zero residual with repair of a small proximal dissection.  minor distal disease of the posterolateral branch and 60% proximal left anterior descending coronary artery stenosis and 50% diagonal stenosis along with 50% stenosis of the first obtuse marginal branch.",37
"diagnoses,1.  term pregnancy.,2.  possible rupture of membranes, prolonged.,procedure:,  induction of vaginal delivery of viable male, apgars 8 and 9.,hospital course:,  the patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  she had small amount of leaking since last night.  on exam, she was positive nitrazine, no ferning was noted.  on ultrasound, her afi was about 4.7 cm.  because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,she was brought to the hospital and begun on pitocin.  once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  she went rapidly to completion over the next hour and a half.  she then pushed for 2 hours delivering a viable male over an intact perineum in an oa presentation.  upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  the baby was vigorous, moving all extremities.  the cord was clamped and cut.  the baby was handed off to mom with nurse present.  apgars were 8 and 9.  placenta was delivered spontaneously, intact.  three-vessel cord with no retained placenta.  estimated blood loss was about 150 ml.  there were no tears.",24
"reason for consultation:,  pericardial effusion.,history of present illness: , the patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness.  low-grade fever was noted last few weeks.  the patient also has chest pain described as dull aching type in precordial region.  no relation to exertion or activity.  no aggravating or relieving factors.  a ct of the chest was done, which shows pericardial effusion.  this consultation is for the same.  the patient denies any lightheadedness or dizziness.  no presyncope or syncope.  activity is fairly stable.,coronary risk factors: , history of borderline hypertension.  no history of diabetes mellitus.  nonsmoker.  cholesterol status is within normal limits.  no history of established coronary artery disease.  family history noncontributory.,family history: , nonsignificant.,past surgical history:  ,hysterectomy and bladder surgery.,medications at home:  ,aspirin and thyroid supplementation.,allergies:,  none.,personal history:,  she is a nonsmoker.  she does not consume alcohol.  no history of recreational drug use.,past medical history:,1.  hypothyroidism.,2.  borderline hypertension.,3.  arthritis.,4.  presentation at this time with chest pain and shortness of breath.,review of systems,constitutional:  weakness, fatigue, and tiredness.,heent:  no history of cataract, blurring of vision, or glaucoma.,cardiovascular:  chest pain.  no congestive heart failure.  no arrhythmia.,respiratory:  no history of pneumonia in the past, valley fever.,gastrointestinal:  epigastric discomfort.  no hematemesis or melena.,urological:  frequency.  no urgency.  no hematuria.,musculoskeletal:  arthritis and muscle weakness.,cns:  no tia.  no cva.  no seizure disorder.,endocrine:  nonsignificant.,hematological:  nonsignificant.,physical examination,vital signs:  pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute.,heent:  atraumatic and normocephalic.,neck:  supple.  neck veins flat.  no significant carotid bruit.,lungs:  air entry bilaterally fair.,heart:  pmi displaced.  s1 and s2 regular.,abdomen:  soft and nontender.,extremities:  no edema.  pulses palpable.  no clubbing or cyanosis.,cns:  grossly intact.,laboratory data:  ,white count of 20 and h&h 13 and 39.  bun and creatinine within normal limits.  cardiac enzyme profile negative.,radiographic studies: , ct of the chest preliminary report, pericardial effusion.  echocardiogram shows pericardial effusion, which appears to be chronic.  there is no evidence of hemodynamic compromise.,impression:,1.  the patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder.  she has elevated white count, possible infection.,2.  pericardial effusion without any hemodynamic compromise, could be chronic.",5
"cc:, stable expressive aphasia and decreased vision.,hx:, this 72y/o woman was diagnosed with a left sphenoid wing meningioma on 6/3/80. she was 59 years old at the time and presented with a 6 month history of increasing irritability and left occipital-nuchal headaches. one month prior to that presentation she developed leftward head turning, and 3 days prior to presentation had an episode of severe dysphasia. a hct (done locally) revealed a homogenously enhancing lesion of the left sphenoid wing. skull x-rays showed deviation of the pineal to the right. she was transferred to uihc and was noted to have a normal neurologic exam (per neurosurgery note). angiography demonstrated a highly vascular left temporal/sphenoid wing tumor. she under went left temporal craniotomy and ""complete resection"" of the tumor which on pathologic analysis was consistent with a meningioma.,the left sphenoid wing meningioma recurred and was excised 9/25/84. there was regrowth of this tumor seen on hct, 1985. a 6/88 hct revealed the left sphenoid meningioma and a new left tentorial meningioma. hct in 1989 revealed left temporal/sphenoid, left tentorial, and new left frontal lesions. on 2/14/91 she presented with increasing lethargy and difficulty concentrating. a 2/14/91, hct revealed increased size and surrounding edema of the left frontal meningioma. the left frontal and temporal meningiomas were excised on 2/25/91. these tumors all recurred and a left parietal lesion developed. she underwent resection of the left frontal meningioma on 11/21/91 due to right sided weakness and expressive aphasia. the weakness partially resolved and though the speech improved following resection it did not return to normal. in may 1992 she experienced 3 tonic-clonic type seizures, all of which began with a jacksonian march up the rle then rue before generalizing. her phenobarbital prophylaxis which she had been taking since her 1980 surgery was increased. on 12/7/92, she underwent a left fronto-temporo-parieto-occipital craniotomy and excision of five meningiomas. postoperatively she developed worsened right sided weakness and expressive aphasia. the weakness and aphasia improved by 3/93, but never returned to normal.",21
"chief complaint: , newly diagnosed high-risk acute lymphoblastic leukemia; extensive deep vein thrombosis, right iliac vein and inferior vena cava (ivc), status post balloon angioplasty, and mechanical and pharmacologic thrombolysis following placement of a vena caval filter.,history of present illness: , the patient was transferred here the evening of 02/23/2007 from hospital with a new diagnosis of high-risk acute lymphoblastic leukemia based on confirmation by flow cytometry of peripheral blood lymphoblasts that afternoon.  history related to this illness probably dates back to october of 2006 when he had onset of swelling and discomfort in the left testicle with what he described as a residual ""lump"" posteriorly.  the left testicle has continued to be painful off and on since.  in early november, he developed pain in the posterior part of his upper right leg, which he initially thought was related to skateboarding and muscle strain.  physical therapy was prescribed and the discomfort temporarily improved.  in december, he noted onset of increasing fatigue.  he used to work out regularly, lifting lifts, doing abdominal exercises, and playing basketball and found he did not have energy to pursue these activities.  he has lost 10 pounds since december and feels his appetite has decreased.  night sweats and cough began in december, for which he was treated with a course of augmentin.  however, both of these problems have continued.  he also began taking accutane for persistent acne in december (this agent was stopped on 02/19/2007).  despite increasing fatigue and lethargy, he continues his studies at university of denver, has a biology major (he aspires to be an ophthalmologist).,the morning of 02/19/2007, he awakened with severe right inguinal and right lower quadrant pain.  he was seen in emergency room where it was noted that he had an elevated wbc of 18,000.  ct scan of the abdomen was obtained to rule out possible appendicitis and on that ct, a large clot in the inferior vena cava extending to the right iliac and femoral veins was found.  he promptly underwent appropriate treatment in interventional radiology with the above-noted angioplasty and placement of a vena caval filter followed by mechanical and pharmacologic thrombolysis.  repeat ultrasound there on 02/20/2007 showed no evidence of deep venous thrombosis (dvt).  continuous intravenous unfractionated heparin infusion was continued.  because there was no obvious cause of this extensive thrombosis, occult malignancy was suspected.  appropriate blood studies were obtained and he underwent a pet/ct scan as part of his diagnostic evaluation.  this study showed moderately increased diffuse bone marrow metabolic activity.  because the wbc continued to rise and showed a preponderance of lymphocytes, the smear was reviewed by pathologist, sheryl asplund, m.d., and flow cytometry was performed on the peripheral blood.  these studies became available the afternoon of 02/23/2007, and confirmed the diagnosis of precursor-b acute lymphoblastic leukemia.  the patient was transferred here after stopping of the continuous infusion heparin and receiving a dose of lovenox 60 mg subcutaneously for further diagnostic evaluation and management of the acute lymphoblastic leukemia (all).,allergies: , no known drug allergies.  he does seem to react to certain adhesives.,current medications:  ,1.  lovenox 60 mg subcutaneously q.12h. initiated.,2.  coumadin 5 mg p.o., was administered on 02/19/2007 and 02/22/2007.,3.  protonix 40 mg intravenous (iv) daily.,4.  vicodin p.r.n.,5.  levaquin 750 mg iv on 02/23/2007.,immunizations: , up-to-date.,past surgical history:  ,the treatment of the thrombosis as noted above on 02/19/2007 and 02/20/2007.,family history:  ,two half-brothers, ages 26 and 28, both in good health.  parents are in good health.  a maternal great-grandmother had a deep venous thrombosis (dvt) of leg in her 40s.  a maternal great-uncle developed leukemia around age 50.  a maternal great-grandfather had bone cancer around age 80.  his paternal grandfather died of colon cancer at age 73, which he had had since age 68.  adult-onset diabetes is present in distant relatives on both sides.,social history:  ,the patient is a student at the university majoring in biology.  he lives in a dorm there.  his parents live in breckenridge.  he admits to having smoked marijuana off and on with friends and drinking beer off and on as well.,review of systems: , he has had emesis off and on related to vicodin and constipation since 02/19/2007, also related to pain medication.  he has had acne for about two years, which he describes as mild to moderate.  he denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain noted above.,physical examination:  ,general:  alert, cooperative, moderately ill-appearing young man.,vital signs:  at the time of admission, pulse was 94, respirations 20, blood pressure 120/62, temperature 98.7, height 171.5 cm, weight 63.04 kg, and pulse oximetry on room air 95%.,hair and skin:  mild facial acne.,heent:  extraocular muscles (eoms) intact.  pupils equal, round, and reactive to light and accommodation (perrla), fundi normal.,cardiovascular:  a 2/6 systolic ejection murmur (sem), regular sinus rhythm (rsr).,lungs:  clear to auscultation with an occasional productive cough.,abdomen:  soft with mild lower quadrant tenderness, right more so than left; liver and spleen each decreased 4 cm below their respective costal margins.,musculoskeletal:  mild swelling of the dorsal aspect of the right foot and distal right leg.  mild tenderness over the prior catheter entrance site in the right popliteal fossa and mild tenderness over the right medial upper thigh.,genitourinary:  testicle exam disclosed no firm swelling with mild nondiscrete fullness in the posterior left testicle.,neurologic:  exam showed him to be oriented x4.  normal fundi, intact cranial nerves ii through xii with downgoing toes, symmetric muscle strength, and decreased patellar deep tendon reflexes (dtrs).,laboratory data:  ,white count 25,500 (26 neutrophils, 1 band, 7 lymphocytes, 1 monocyte, 1 myelocyte, 64 blasts), hemoglobin 13.3, hematocrit 38.8, and 312,000 platelets.  electrolytes, bun, creatinine, phosphorus, uric acid, ast, alt, alkaline phosphatase, and magnesium were all normal.  ldh was elevated to 1925 units/l (upper normal 670), and total protein and albumin were both low at 6.2 and 3.4 g/dl respectively.  calcium was also slightly low at 8.8 mg/dl.  low molecular weight heparin test was low at 0.27 units/ml.  pt was 11.8, inr 1.2, and fibrinogen 374.  urinalysis was normal.,assessment: , 1.  newly diagnosed high-risk acute lymphoblastic leukemia.,2.  deep vein thrombosis of the distal iliac and common femoral/right femoral and iliac veins, status post vena caval filter placement and mechanical and thrombolytic therapy, on continued anticoagulation.,3.  probable chronic left epididymitis.,plan: , 1.  proceed with diagnostic bone marrow aspirate/biopsy and lumbar puncture (using a #27-gauge pencil-tip needle for minimal trauma) as soon as these procedures can be safely done with regard to the anticoagulation status.,2.  prompt reassessment of the status of the deep venous thrombosis with doppler studies.,3.  ultrasound/doppler of the testicles.,4.  maintain therapeutic anticoagulation as soon as the diagnostic procedures for all can be completed.,",3
"reason for visit: , kyphosis.,history of present illness: , the patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  the patient has a family history in a maternal aunt and grandfather of kyphosis.  she was noted by her parents to have round back posture.  they have previously seen another orthopedist who recommended observation at this time.  she is here for a second opinion in regards to kyphosis.  the patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  no problems with her bowels or bladder.,past medical history: , none.,past surgical history: , bilateral pinning of her ears.,social history:  ,she is currently an eighth grader at middle school and is interested in basketball.  she lives with both of her parents and has a 9-year-old brother.  she had menarche beginning in september.,family history:  ,of kyphosis in great grandmother and second cousin.,review of systems: , she is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,medications: , she is currently on zyrtec, flonase, and ceftin for an ear infection.,allergies: , no known drug allergies.,findings: , on physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  in regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  no cafe au lait spots.  she is not tender to palpation from her occiput to her sacrum.  there is no evidence of paraspinal muscle spasm.  on forward bending, there is a mild kyphosis.  she is not able to touch her toes indicating her hamstring tightness.  she has a full 5 out of 5 in all muscle groups.  her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  her sensation intact to light touch in l1 through l2 dermatomal distributions.  she has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,x-rays today included pa and lateral sclerosis series.  she has approximately 46 degree kyphosis.,assessment: , kyphosis.,plans:  ,the patient's kyphosis is quite mild.  while this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  at this time, three options were discussed with the parents including observation, physical therapy, and bracing.  at this juncture, given that she has continued to grow, they are risser 0.  she may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  as such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  we will see her back in 3 months' time for repeat radiographs at that time including pa and lateral standing of scoliosis series.  should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  we will see her back in 3 months' time for repeat evaluation.",26
"preoperative diagnosis: , hemarthrosis, left knee, status post total knee replacement, rule out infection.,postoperative diagnosis: , hemarthrosis, left knee, status post total knee replacement, rule out infection.,operations:,1.  arthrotomy, left total knee.,2.  irrigation and debridement, left knee.,3.  polyethylene exchange, left knee.,complication: , none.,tourniquet time:  ,58 minutes.,estimated blood loss: , minimal.,anesthesia:  ,general.,indications:  ,this patient underwent an uncomplicated left total knee replacement.  postoperatively, unfortunately did not follow up with pt/inr blood test and he was taking coumadin.  his inr was seemed to elevated and developed hemarthrosis.  initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,this procedure as well as alternatives was discussed in length with the patient and he understood them well.  risks and benefits were also discussed.  risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  he understood them well.  all questions were answered and he signed consent for the procedure as described.,description of procedure: , the patient was placed on operating table and general anesthesia was achieved.  the left lower extremity was then prepped and draped in the usual sterile manner.  the leg was elevated and the tourniquet was inflated to 325 mmhg.  a longitudinal incision was then made and carried down through subcutaneous tissues.  this was made through the prior incision site.  there were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  medial and lateral flaps were then made.  the prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  effusion within the knee was noted.  all hematoma was evacuated.  i then did flex the knee and removed the polyethylene.  once the polyethylene was removed i did irrigate the knee with total of 9 liters of antibiotic solution.  further debridement was performed of all inflamed tissue and thickened synovial tissue.  a 6 x 16-mm stryker polyethylene was then snapped back in position.  the knee has excellent stability in all planes and i did perform a light manipulation to improve the flexion of the knee.  further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  the knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 ethibond suture in a figure-of-eight manner.  the subcutaneous tissue was reapproximated in layers using #1 and 2-0 vicryl sutures, and the skin was reapproximated using staples.  prior to closure a hemovac drain was inserted through a superolateral approach into the knee joint.,no complications were encountered throughout the procedure, and the patient tolerated the procedure well.  the patient was taken to recovery room in stable condition.",37
"preoperative diagnoses: , term pregnancy, nonreassuring fetal heart tracing.,postoperative diagnoses: , term pregnancy, nonreassuring fetal heart tracing.,operation:,  primary cesarean section by low-transverse incision.,anesthesia:,  epidural.,estimated blood loss: , 450 ml.,complications: , none.,condition: , stable.,drains:  ,foley catheter.,indications: , the patient is a 39-year-old, g4, para 0-0-3-0, with an edc of 03/08/2009.  the patient began having prodromal symptoms 2 to 3 days prior to presentation.  she was seen on 03/09/2007 and a nonstress test was performed.  this revealed some spontaneous variable-appearing decelerations.  she was given iv hydration.  a biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  therefore, she was admitted for further fetal monitoring and evaluation.  she had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  she was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  due to these findings, a scalp electrode was placed as well as an iupc for an amnioinfusion.  this relieved the decelerations somewhat.  however, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  these findings were reviewed with the patient and recommendation was made for cesarean section delivery.  the risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,procedure: , the patient was taken to the operating room where her epidural anesthesia was reinforced.  she was prepped and draped in the usual fashion for the procedure.  after adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  this incision was carried down to the level of the fascia, which was also transversely incised.  after adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  the rectus muscle was separated in midline exposing the peritoneum.  the peritoneum was carefully grasped and elevated with hemostats.  it was entered in an up and down fashion with metzenbaum scissors.  the bladder blade was placed in the lower pole of the incision to protect the bladder.,the uterus was palpated and inspected.  a thin lower uterine segment was noted.  the vertex presentation was confirmed.  the scalp was then utilized to make a transverse or kerr incision in the lower uterine wall.  clear fluid was noted upon entering into the amniotic space.  at 05:27, a term viable female infant was delivered up through the incision.  she had spontaneous respirations.  she was given bulb suctioning for clear fluid.  her cord was clamped and cut and she was delivered off the field to dr. x who was attending.  the baby girl was subsequently signed apgars of 8 at one minute and 9 at five minutes.  her birth weight was found to be 5 pounds and 5 ounces.,the placenta was manually extracted from the endometrial cavity.  a ring clamp and two allis clamps were placed around the margin of the uterine incision for hemostasis.  the uterus was delivered up into the operative field.  the endometrial cavity was swiped clean with a moist laparotomy pad.  the uterine incision was then closed in a two-layered fashion with 0 vicryl suture, the first layer interlocking and the second layer imbricating.  two additional stitches of 3-0 vicryl suture were utilized for hemostasis.  the uterine incision was noted to be hemostatic upon closure.  the uterus was rotated forward, normal tubes and ovaries were noted on both sides.  the uterus was then returned to its normal position of the abdominal cavity.  the sponge and instrument count was performed for the first time at this point and found to be correct.  the pelvis and anterior uterine space was then irrigated with saline solution.  it was suctioned dry.  a final check of the uterine incision confirmed hemostasis.  the rectus muscle was stabilized across the midline with two simple stitches of 0 vicryl suture.  the subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 vicryl suture, beginning in lateral margins and overlapping the midline.  the subcutaneous tissue was then irrigated and inspected.  no active bleeding was noted.  it was closed with a running length of 3-0 plain catgut suture.  the skin was then approximated with surgical steel staples.  the incision was infiltrated with a 0.5% solution of marcaine local anesthetic.  the incision was cleansed and sterilely dressed.,the patient was transferred to the recovery room in stable condition.  the estimated blood loss through the procedure was 450 ml.  the sponge and instrument counts were performed two more times during closure and found to be correct each time.",23
"preoperative diagnosis:,  subglottic stenosis.,postoperative diagnosis: , subglottic stenosis.,operative procedures: , direct laryngoscopy and bronchoscopy.,anesthesia:,  general inhalation.,description of procedure: , the patient was taken to the operating room and placed supine on the operative table.  general inhalational anesthesia was administered through the patient's tracheotomy tube.  the small parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  there was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  the stoma showed some suprastomal fibroma.  the remaining tracheobronchial passages were clear.  the patient's 3.5 neonatal tracheostomy tube was repositioned and secured with velcro ties.  bleeding was negligible.  there were no untoward complications.  the patient tolerated the procedure well and was transferred to recovery room in stable condition.",3
"subjective:,  the patient is a 49-year-old white female, established patient to dermatology, last seen in the office on 08/10/2004.  she comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  on examination, this is a flaring of her acne with small folliculitis lesions.  the patient has been taking amoxicillin 500 mg b.i.d. and using tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  she has also been getting photofacials at healing waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  the patient is married.  she is a secretary.,family, social, and allergy history:,  she has hay fever, eczema, sinus, and hives.  she has no melanoma or skin cancers or psoriasis.  her mother had oral cancer.  the patient is a nonsmoker.  no blood tests.  had some sunburn in the past.  she is on benzoyl peroxide and daypro.,current medications:,  lexapro, effexor, ditropan, aspirin, vitamins.,physical examination:,  the patient is well developed, appears stated age.  overall health is good.  she has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,impression:,  acne with folliculitis.,treatment:,1.  discussed condition and treatment with the patient.,2.  continue the amoxicillin 500 mg two at bedtime.,3.  add septra ds every morning with extra water.,4.  continue the tazorac cream 0.1; it is okay to use on back and chest also.,5.  referred to abc clinic for an aesthetic consult.  return in two months for followup evaluation of her acne.",8
"preoperative diagnosis:,  bilateral upper eyelid dermatochalasis.,postoperative diagnosis: , same.,procedure: , bilateral upper lid blepharoplasty, (cpt 15822).,anesthesia: , lidocaine with 1:100,000 epinephrine.,description of procedure: , this 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction.  the procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient.  all questions have been thoroughly answered, and the patient understands the surgery indicated.  she has requested this corrective repair be undertaken, and a consent was signed.,the patient was brought into the operating room and placed in the supine position on the operating table.  an intravenous line was started, and sedation and sedation anesthesia was administered iv after preoperative p.o. sedation.  the patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.  the excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen.  the surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,the upper eyelid areas were bilaterally injected with 1% lidocaine with 1:100,000 epinephrine for anesthesia and vasoconstriction.  the plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,the face was prepped and draped in the usual sterile manner.,after waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection.  hemostasis was obtained with a bipolar cautery.  a thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right.  the defect in the orbital septum was identified, and herniated orbital fat was exposed.  the abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit.  a similar procedure was performed exposing herniated portion of the nasal pocket.  great care was taken to obtain perfect hemostasis with this maneuver.  a similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion.  careful hemostasis had been obtained on the upper lid areas.  the lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue prolene sutures.,at the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact.  there was no diplopia, no ptosis, no ectropion.  wounds were reexamined for hemostasis, and no hematomas were noted.  cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,the procedures were completed without complication and tolerated well.  the patient left the operating room in satisfactory condition.  a follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,the patient was released to return home in satisfactory condition.",25
"preoperative diagnosis:,  left supraorbital deep complex facial laceration measuring 6x2 cm.,postoperative diagnosis: , left supraorbital deep complex facial laceration measuring 6x2 cm.,procedure performed: , plastic closure of deep complex facial laceration measuring 6x2 cm.,anesthesia: , local anesthesia with 1% lidocaine with 1:100,000 epinephrine, total of 2 cc were used.,specimens: , none.,findings: , deep complex left forehead laceration.,history: , the patient is a 23-year-old male who was intoxicated and hit with an unknown object to his forehead.  the patient subjectively had loss of consciousness on the scene and minimal bleeding from the left supraorbital laceration site.  he was brought to the emergency room, where a cat scan of the head and facial bumps was performed, which were negative.,prior to performing surgery informed consent was obtained from the patient who was well aware of the risks, benefits, alternatives and complications of the surgery to include infection, bleeding, cosmetic deformity, significant scarring, need for possible scar revision.  the patient was allowed to ask all questions he wanted, and they were answered in a language he could understand.  he wished to pursue surgery and signed the informed consent.,procedure: , the patient was placed in the supine position.  the wound was copiously irrigated with normal saline on irrigating tip.  after one liter of irrigation, the wound was prepped and draped in the usual sterile fashion.  the incision was then localized with a solution of 1% lidocaine with 1:100,000 epinephrine, a total of less than 2 cc was used.  we then reapproximated the wound in double-layered fashion with deep sutures of #5-0 vicryl, two interrupted sutures were used, and then the skin was closed with interrupted sutures of #5-0 nylon.  the wound came together very nicely.  tincture of benzoin was placed.  steri-strips were placed over the top and a small amount of bacitracin was placed over the steri-strips.  the patient tolerated the procedure well with no complications.",37
"history of present illness: , the patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago.  there is a nodule in her lung, which was treated by excision in february of 2007 on the right side.  she had spread to her kidney.  she had right-sided nephrectomy and left-sided nephrostomy.  she also had invasion of the bladder.  currently, all of her urine comes out through the renal nephrostomy.  she complains of burning vaginal pain, as well as chronic discharge, which has improved slightly recently.  she is not able to engage in intercourse because of the pain and bleeding.  she also has pain with bowel movements, as well as painful urgency.  the pain is at least 3-4/10 and is partially relieved with methadone rescues and interferes with her ability to sleep at night as she feels exhausted and tired.  she has some nausea and diminished appetite.  no hallucinations.  she is anxious frequently and this is helped with clonazepam, which she has taken chronically for her anxiety disorder and recently started zyprexa.  she has occasional shortness of breath, which used to be helped with oxygen in the hospital.,past medical history:,  peptic ulcer disease, hypertension.,review of systems:,  she has constipation with hard bowel movements.,medications:,  norvasc 10 mg daily, isosorbide 60 mg every 24 hours, olanzapine at 2.5-5 mg in bedtime, clonazepam 1 mg every eight hours, sorbitol 30 cc twice a day, senna-s two tabs daily, methadone 60 mg every eight hours, and 30 mg every four hours p.r.n. pain.,allergies:,  she has no known allergies.,social history: , the patient lives with her common law husband and her daughter.  code status: dnr.  religion.  catholic.  she has a past history of heroin use and was enrolled in mmtp program for 12 hours.  she reports feeling discouraged from her symptoms and pain.,physical examination: , blood pressure 120/80, pulse 80, and respirations 14.  general appearance:  mildly obese woman.  perrla, 3 mm.  oral mucosa moist without lesions.  lungs:  clear.  heart:  rrr without murmurs.  abdomen:  somewhat distended, but soft and nontender.  there is firmness found in the low abdomen bilaterally.  there is erythema in the intertriginous area and vulva, as well as some serous discharge from the vagina.  neurological exam:  cranial nerves ii through xii are grossly intact.  there is normal tone.  power is 5-/5.  dtrs nonreactive.  sensation intact to fine touch.  mental status:  the patient is alert, fully oriented, normal speech, and thought process.  normal affect.,assessment and plan: , ,1.  carcinoma of the cervix metastatic to the retroperitoneum, bladder, and lung with irritable obstruction and gradual decline in the performance status.  given this, her prognosis is likely to be limited to six months and she will benefit from home hospice care.,2.  pain, which is a combination of somatic nociceptive pain due to the retroperitoneal invasion, as well as a neuropathic component from pelvic and nerve involvement by the surgery as well as radiation therapy and disease itself.  we are going to increase methadone to 70 mg every eight hours and continue 30 mg for breakthrough.  we will add pregabalin 50 mg three times a day and titrate the dose up as needed.,3.  nausea and poor appetite.  we will start megace 200 mg daily.,4.  shortness of breath.  we will provide oxygen p.r.n.,5.  candidal infection.  we will start clotrimazole 1% cream b.i.d.,6.  constipation.  we will advance the bowel regimen to sorbitol 30 cc three times a day and senna-s three tabs twice a day.,7.  psychosocial.  the patient is getting discouraged.  we will provide supportive counseling.,length of the encounter was 80 minutes; more than half spent on exchange of information.,thank you for the opportunity to participate in the care for this patient.",17
"testicular ultrasound,reason for exam:  ,left testicular swelling for one day.,findings:  ,the left testicle is normal in size and attenuation, it measures 3.2 x 1.7 x 2.3 cm.  the right epididymis measures up to 9 mm.  there is a hydrocele on the right side.  normal flow is seen within the testicle and epididymis on the right.,the left testicle is normal in size and attenuation, it measures 3.9 x 2.1 x 2.6 cm.  the left testicle shows normal blood flow.  the left epididymis measures up to 9 mm and shows a markedly increased vascular flow.  there is mild scrotal wall thickening.  a hydrocele is seen on the left side.,impression:,1.  hypervascularity of the left epididymis compatible with left epididymitis.,2.  bilateral hydroceles.",32
"history of present illness:,  this is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  his most recent bun and creatinine on 04/04/06 are 40/2.0, which is stable.  he denies any chest pain or tightness in his chest.  he denies any shortness of breath, nausea, or vomiting.  he denies any change to his appetite.  he denies any fevers, chills, dysuria, or hematuria.  he does report his blood pressure being checked at the senior center and reporting that it is improved.  the patient has stage iii chronic kidney disease. ,past medical history:,",24
"admitting diagnosis: , right c5-c6 herniated nucleus pulposus.,primary operative procedure: , anterior cervical discectomy at c5-6 and placement of artificial disk replacement.,summary:,  this is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including esis.  she underwent another mri and significant degenerative disease at c5-6 with a central and right-sided herniation was noted.  risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  she was interested in participating in the artificial disk replacement study and was entered into that study.  she was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  she has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  she will have x-rays ap and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  she will follow up with dr. x in 2 weeks in the clinic as per the study protocol with cervical ap and lateral x-rays with ring prior to the appointment.  she will contact our office prior to her appointment if she has problems.  prescriptions were written for flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.",22
"preoperative diagnosis:,  wrist de quervain stenosing tenosynovitis.,postoperative diagnosis: , wrist de quervain stenosing tenosynovitis.,title of procedures,1. de quervain release.,2.  fascial lengthening flap of the 1st dorsal compartment.,anesthesia:,  mac.,complications: , none.,procedure in detail: , after mac anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  the arm was exsanguinated with an esmarch and the tourniquet inflated to 250 mmhg.,i made a transverse incision just distal to the radial styloid.  dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  meticulous hemostasis was maintained with bipolar electrocautery.,i dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  i then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  the epb subsheath was likewise released.,i irrigated the wound thoroughly.  in order to prevent tendon subluxation, i then back-cut both the dorsal and volar leafs of the sheath so that i could close them in an extended and lengthened position.  i did this with 3-0 vicryl.  i then passed an instrument underneath to check and make sure that the sheath was not too tight.  i then irrigated it and closed the skin, and then i dressed and splinted the wrist appropriately.  the patient was sent to the recovery room in good condition, having tolerated the procedure well.",26
"history:,  the patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  symptoms worsened considerable about a month ago.  this normally occurs after being on her feet for any length of time.  she was started on amitriptyline and this has significantly improved her symptoms.  she is almost asymptomatic at present.  she dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  she has had no associated weakness.,on brief examination, straight leg raising is normal.  the patient is obese.  there is mild decreased vibration and light touch in distal lower extremities.  strength is full and symmetric.  deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,nerve conduction studies: , bilateral sural sensory responses are absent.  bilateral superficial sensory responses are present, but mildly reduced.  the right radial sensory response is normal.  the right common peroneal and tibial motor responses are normal.  bilateral h-reflexes are absent.,needle emg:,  needle emg was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  it revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  lumbar paraspinals were attempted, but were too painful to get a good assessment.,impression:  ,this electrical study is abnormal.  it reveals the following:,1.  a very mild, purely sensory length-dependent peripheral neuropathy.,2.  mild bilateral l5 nerve root irritation.  there is no evidence of active radiculopathy.,based on the patient's history and exam, her new symptoms are consistent with mild bilateral l5 radiculopathies.  symptoms have almost completely resolved over the last month since starting elavil.  i would recommend mri of the lumbosacral spine if symptoms return.  with respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  however, i would recommend a workup for other causes to include the following:  fasting blood sugar, hba1c, esr, rpr, tsh, b12, serum protein electrophoresis and lyme titer.",21
"she has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  she has also had bilateral carpal tunnel release.,on examination, normal range of movement of c-spine.  she has full strength in upper and lower extremities.  normal straight leg raising.  reflexes are 2 and symmetric throughout.  no babinski.  she has numbness to light touch in her right big toe.,nerve conduction studies:  the right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  bilateral tibial motor nerves could not be obtained (technical).  the remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, f-waves, and h. reflexes.,needle emg:  needle emg was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left fdi.  it revealed 2+ spontaneous activity in the right apb and fdi and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  there was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,impression:  this electrical study is abnormal.  it reveals the following:,1.  an active right c8/t1 radiculopathy.  electrical abnormalities are moderate.,2.  an active right c6/c7 radiculopathy.  electrical abnormalities are mild.,3.  evidence of chronic left c8/t1 denervation.  no active denervation.,4.  mild right lumbosacral radiculopathies.  this could not be further localized because of normal emg testing in the lower extremity muscles.,5.  there is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,results were discussed with the patient.  it appears that she has failed conservative therapy and i have recommended to her that she return to dr. x for his assessment for possible surgery to her c-spine.  she will continue with conservative therapy for the mild lumbosacral radiculopathies.",32
"interpretation: , mri of the cervical spine without contrast showed normal vertebral body height and alignment with normal cervical cord signal.  at c4-c5, there were minimal uncovertebral osteophytes with mild associated right foraminal compromise.  at c5-c6, there were minimal diffuse disc bulge and uncovertebral osteophytes with indentation of the anterior thecal sac, but no cord deformity or foraminal compromise.  at c6-c7, there was a central disc herniation resulting in mild deformity of the anterior aspect of the cord with patent neuroforamina.  mri of the thoracic spine showed normal vertebral body height and alignment.  there was evidence of disc generation, especially anteriorly at the t5-t6 level.  there was no significant central canal or foraminal compromise.  thoracic cord normal in signal morphology.  mri of the lumbar spine showed normal vertebral body height and alignment.  there is disc desiccation at l4-l5 and l5-s1 with no significant central canal or foraminal stenosis at l1-l2, l2-l3, and l3-l4.  there was a right paracentral disc protrusion at l4-l5 narrowing of the right lateral recess.  the transversing nerve root on the right was impinged at that level.  the right foramen was mildly compromised.  there was also a central disc protrusion seen at the l5-s1 level resulting in indentation of the anterior thecal sac and minimal bilateral foraminal compromise.,impression: , overall impression was mild degenerative changes present in the cervical, thoracic, and lumbar spine without high-grade central canal or foraminal narrowing.  there was narrowing of the right lateral recess at l4-l5 level and associated impingement of the transversing nerve root at that level by a disc protrusion.  this was also seen on a prior study.,",26
"procedure performed:,1.  left heart catheterization, left ventriculogram, aortogram, coronary angiogram.,2.  pci of the lad and left main coronary artery with impella assist device.,indications for procedure: , unstable angina and congestive heart failure with impaired lv function.,technique of procedure: , after obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  the right groin was prepped and draped in the usual sterile manner.  lidocaine 2% was used for infiltration anesthesia.  using modified seldinger technique, a 7-french sheath was introduced into the right common femoral artery and a 6-french sheath was introduced into the right common femoral vein.  through the arterial sheath, angiography of the right common femoral artery was obtained.  thereafter, 6-french pigtail catheter was advanced to the level of the distal aorta where angiography of the distal aorta and the bifurcation of the right and left common iliac arteries was obtained.  thereafter, a 4-french sheath was introduced into the left common femoral artery using modified seldinger technique.  thereafter, the pigtail catheter was advanced over an 0.035-inch j-wire into the left ventricle and lv-gram was performed in rao view and after pullback, an aortogram was performed in the lao view.  therefore, a 6-french jl4 and jr4 guiding catheters were used to engage the left and right coronary arteries respectively and multiple orthogonal views of the coronary arteries were obtained.,angiographic findings:  ,1.  lv-gram:  lvedp was 15 mmhg.  lv ejection fraction 10% to 15% with global hypokinesis.  only anterior wall is contracting.  there was no mitral regurgitation.  there was no gradient across the aortic valve upon pullback, and on aortography, there was no evidence of aortic dissection or aortic regurgitation.,2.  the right coronary artery is a dominant vessels with a mid 50% to 70% stenosis which was not treated.  the left main coronary artery calcified vessel with disease.,2.  the left anterior descending artery had an 80% to 90% mid-stenosis.  first diagonal branch had a more than 90% stenosis.,3.  the circumflex coronary artery had a patent stent.,intervention: , after reviewing the angiographic images, we elected to proceed with intervention of the left anterior descending artery.  the 4-french sheath in the left common femoral artery was upsized to a 12-french impella sheath through which an amplatz wire and a 6-french multipurpose catheter were advanced into the left ventricle.  the amplatz wire was exchanged for an impella 0.018-inch stiff wire.  the multipurpose catheter was removed, and the impella was advanced into the left ventricle and a performance level of 8 was achieved with a cardiac output of 2 to 2.5 l/min.  thereafter, a 7-french jl4 guiding catheter was used to engage the left coronary artery and an asahi soft 0.014-inch wire was advanced into the left anterior descending artery and a second 0.014-inch asahi soft wire was advanced into the diagonal branch.  the diagonal branch was predilated with a 2.5 x 30-mm sprinter balloon at nominal atmospheres and thereafter a 2.5 x 24 endeavor stent was successfully deployed in the mid-lad and a 3.0 x 15-mm endeavor stent was deployed in the proximal lad.  the stent delivery balloon was used to post-dilate the overlapping segment.  the lad, the diagonal was rewires with an 0.014-inch asahi soft wire and a 3.0 x 20-mm maverick balloon was advanced into the lad for post-dilatation and a 2.0 x 30-mm sprinter balloon was advanced into the diagonal for kissing inflations which were performed at nominal atmospheres.  at this point, it was noted that the left main had a retrograde dissection.  a 3.5 x 18-mm endeavor stent was successfully deployed in the left main coronary artery.  the asahi soft wire in the diagonal was removed and placed into the circumflex coronary artery.  kissing inflations of the lad and the circumflex coronary artery were performed using 3.0 x 20 maverick balloons x2 balloons, inflated at high atmospheres of 14.,results: , lesion reduction in the lad from 90% to 0% and timi 3 flow obtained.  lesion reduction in the diagonal from 90% to less than 60% and timi 3 flow obtained.  lesion reduction in the left maintained coronary artery from 50% to 0% and timi 3 flow obtained.,the patient tolerated the procedure well and the inflations well with no evidence of any hemodynamic instability.  the impella device was gradually decreased from performance level of 8 to performance level of 1 at which point it was removed into the aorta and it was turned off and the impella was removed from the body and the 2 perclose sutures were tightened.  from the right common femoral artery, a 6-french ima catheter was advanced and an 0.035-inch wire down into the left common femoral and superficial femoral artery, over which an 8 x 40 balloon was advanced and tamponade of the arteriotomy site of the left common femoral artery was performed from within the artery at 3 atmospheres for a total of 20 minutes.  the right common femoral artery and vein sheaths were both sutured in place for further observation.  of note, the patient received angiomax during the procedure and an act above 300 was maintained.,impression:,1.  left ventricular dysfunction with ejection fraction of 10% to 15%.,2.  high complex percutaneous coronary intervention of the left main coronary artery, left anterior descending artery, and diagonal with impella circulatory support.,complications: , none.,the patient tolerated the procedure well with no complications.  the estimated blood loss was 200 ml.  estimated dye used was 200 ml of visipaque.  the patient remained hemodynamically stable with no hypotension and no hematomas in the groins.,plan:  ,1.  aspirin, plavix, statins, beta blockers, ace inhibitors as tolerated.,2.  hydration.,3.  the patient will be observed over night for any hemodynamic instability or ischemia.  if she remains stable, the right common femoral artery and vein sheaths will be removed and manual pressure will be applied for hemostasis.",37
"chief complaint: , congestion and cough.,history of present illness:  ,the patient is a 5-month-old infant who presented initially on monday with a cold, cough, and runny nose for 2 days.  mom states she had no fever.  her appetite was good but she was spitting up a lot.  she had no difficulty breathing and her cough was described as dry and hacky.  at that time, physical exam showed a right tm, which was red.  left tm was okay.  she was fairly congested but looked happy and playful.  she was started on amoxil and aldex and we told to recheck in 2 weeks to recheck her ear.  mom returned to clinic again today because she got much worse overnight.  she was having difficulty breathing.  she was much more congested and her appetite had decreased significantly today.  she also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,allergies: , she has no known drug allergies.,medications:  ,none except the amoxil and aldex started on monday.,past medical history:  ,negative.,social history: , she lives with mom, sister, and her grandparent.,birth history: , she was born, normal spontaneous vaginal delivery at woman's weighing 7 pounds 3 ounces.  no complications.  prevented, she passed her hearing screen at birth.,immunizations: , also up-to-date.,past surgical history: , negative.,family history:  ,noncontributory.,physical examination:,vital signs:  her respiratory rate was approximately 60 to 65.,general:  she was very congested and she looked miserable.  she had no retractions at this time.,heent:  her right tm was still red and irritated with no light reflex.  her nasal discharge was thick and whitish yellow.  her throat was clear.  her extraocular muscles were intact.,neck:  supple.  full range of motion.,cardiovascular exam:  she was tachycardic without murmur.,lungs:  revealed diffuse expiratory wheezing.,abdomen:  soft, nontender, and nondistended.,extremities:  showed no clubbing, cyanosis or edema.,laboratory data:  ,her chem panel was normal.  rsv screen is positive.  chest x-ray and cbc are currently pending.,impression and plan:  ,rsv bronchiolitis with otitis media.  admit for oral orapred, iv rocephin, nebulizer treatments and oxygen as needed.",5
"external examination: , the autopsy is begun at 8:30 a.m. on may 24, 2004. the body is presented in a black body bag. the victim is wearing a white sleeveless turtleneck shirt and navy blue sweatpants. jewelry included two smooth-textured silver hoop pierced earrings, 1-inch diameter, one in each ear, and one 1-inch wide silver expandable wristband on left wrist. a 1.5-inch wide tan belt with green stripes is cinched around the upper neck using the buckle. the opposite end of the belt is tied in a half-hitch knot, which was used to affix it to the crossbar in the closet where the body was found. ,the body is that of a normally developed white female measuring 67 inches and weighing 118 pounds, and appearing generally consistent with the stated age of twenty-six years. the body is cold and unembalmed. lividity is fixed in the distal portions of the limbs. the eyes are open. the irises are brown and corneas are cloudy. petechial hemorrhaging is present in the conjunctival surfaces of the eyes. the pupils measure 0.3 cm. the hair is dark blonde with lighter blonde highlights, wavy, layered and approximately 11 inches in length at the longest point. ,removal of the belt revealed a ligature mark (known throughout this report as ligature a) on the neck below the mandible. ligature a is approximately 1.5 inches wide and encircles the neck in the form of a ""v"" on the anterior of the neck and an inverted ""v"" on the posterior of the neck, consistent with hanging. minor abrasions are present in the area of ligature a. lack of hemorrhage surrounding ligature a indicates this injury to be post-mortem. ,upon removal of the victim's clothing, an odor of bleach was detected. areas of the body were swabbed and submitted for detection of hypochlorite. following removal of the shirt, a second ligature mark (known throughout this report as ligature b) was observed on the victim's neck. the mark is dark red ligature and encircles the neck, crossing the anterior midline of the neck just below the laryngeal prominence. the width of the mark varies between 0.8 and 1cm and is horizontal in orientation. the skin of the anterior neck above and below the ligature mark shows petechial hemorrhaging. ligature b is not consistent with the belt that caused ligature a. the absence of abrasions associated with ligature b, along with the variations in the width of the ligature mark, are consistent with a soft ligature, such as a length of fabric. no trace evidence was recovered from ligature b that might assist in identification of the ligature used. ,the genitalia are that of an adult female and there is no evidence of injury. pubic hair has been shaved in its entirety within six hours of death. limbs are equal, symmetrically developed and show no evidence of injury. the fingernails are medium length and fingernail beds are blue. there are no residual scars, markings or tattoos.,internal examination:  ,head--central nervous system: ,subsequent autopsy shows a broken hyoid bone. hemorrhaging from ligature b penetrates the skin and subdermal tissues of the neck. the brain weighs 1,303 grams and within normal limits. ,skeletal system:, the hyoid bone is fractured. ,respiratory system--throat structures: ,the oral cavity shows no lesions. petechial hemorrhaging is present in the mucosa of the lips and the interior of the mouth. otherwise, the mucosa is intact and there are no injuries to the lips, teeth or gums. ,there is no obstruction of the airway. the mucosa of the epiglottis, glottis, piriform sinuses, trachea and major bronchi are anatomic. no injuries are seen and there are no mucosal lesions. the hyoid bone, the thyroid, and the cricoid cartilages are fractured. ,the lungs weigh: right, 355 grams; left 362 grams. the lungs are unremarkable. ,cardiovascular system: ,the heart weighs 253 grams, and has a normal size and configuration. no evidence of atherosclerosis is present. ,gastrointestinal system: ,the mucosa and wall of the esophagus are intact and gray-pink, without lesions or injuries. the gastric mucosa is intact and pink without injury. approximately 125 ml of partially digested semisolid food is found in the stomach. the mucosa of the duodenum, jejunum, ileum, colon and rectum are intact. ,urinary system: ,the kidneys weigh: left, 115 grams; right, 113 grams. the kidneys are anatomic in size, shape and location and are without lesions. ,female genital system: ,the structures are within normal limits. examination of the pelvic area indicates the victim had not given birth and was not pregnant at the time of death. there is evidence of recent sexual activity but no indications that the sexual contact was forcible. vaginal fluid samples are removed for analysis. ,toxicology: ,sample of right pleural blood and bile are submitted for toxicologic analysis. stomach contents are saved. ,serology:, a sample of right pleural blood is submitted in the edta tube. routine toxicologic studies were ordered.,laboratory data,cerebrospinal fluid culture and sensitivity:,gram stain: unremarkable,culture: no growth after 72 hours,cerebrospinal fluid bacterial antigens:,hemophilus influenza b: negative,streptococcus pneumoniae: negative,n. meningitidis: negative,neiserria meningitidis b/e. coli k1: negative ,drug screen results:,urine screen {immunoassay} was negative. ,ethanol: 0 gm/dl, blood (heart),ethanol: 0 gm/dl, vitreous ,evidence collected:,1. one (1) white turtleneck sleeveless shirt, size small. ,2. one (1) pair navy blue sweatpants, size small.,3. two (2) silver hoop earrings. ,4. one (1) silver bracelet.,5. samples of blood (type o+), bile, and tissue (heart, lung, brain, kidney, liver, spleen). ,6. fifteen (15) swabs from various body locations, to be tested for presence of hypochlorite.,7. eleven (11) autopsy photographs. ",1
"chief complaint: , newly diagnosed t-cell lymphoma.,history of present illness: , the patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  he was originally treated with antibiotics as a possible tooth abscess.  prior to this event, in march of 2010, he was treated for strep throat.  the pain at that time was on the right side.  about a month ago, he started having night sweats.  the patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  all these symptoms were preceded by overwhelming fatigue and exhaustion.  he reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  with the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  he also reports occasional headaches with some stabbing and pain in his feet and legs.  he also complains of some left groin pain.,past medical history: , significant for hiv diagnosed in 2000.  he also had mononucleosis at that time.  the patient reports being on anti-hepatitis viral therapy period that was very intense.  he took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  he reports no other history of transfusions.  he has history of spontaneous pneumothorax.  the first episode was 1989 on his right lung.  in 1990 he had a slow collapse of the left lung.  he reports no other history of pneumothoraces.  in 2003, he had shingles.  he went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,family history: , notable for his mother who is currently battling non-small cell lung cancer.  she is a nonsmoker.  his sister is epstein-barr virus positive.  the patient's mother also reports that she is epstein-barr virus positive.  his maternal grandfather died from complications from melanoma.  his mother also has diabetes.,social history: , the patient is single.  he currently lives with his mother in house for several both in new york and here in colorado.  his mother moved out to colorado eight years ago and he has been out here for seven years.  he currently is self employed and does antiquing.  he has also worked as nurses' aide and worked in group home for the state of new york for the developmentally delayed.  he is homosexual, currently not sexually active.  he does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  he does not use alcohol or illicit drugs.,review of systems: , as mentioned above his weight has been fairly stable.  although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  he has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  he has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  he has had fevers as well.  the rest of his review of systems is negative.,physical exam:,vitals:",5
"reason for referral:,  evaluation for right l4 selective nerve root block.,chief complaint:,",26
"general: , vital signs and temperature as documented in nursing notes.  the patient appears stated age and is adequately developed.,eyes:,  pupils are equal, round, reactive to light and accommodation.  lids and conjunctivae reveal no gross abnormality.,ent:  ,hearing appears adequate.  no obvious asymmetry or deformity of the ears and nose.,neck: , trachea midline.  symmetric with no obvious deformity or mass; no thyromegaly evident.,respiratory:,  the patient has normal and symmetric respiratory effort.  lungs are clear to auscultation.,cardiovascular: , s1, s2 without significant murmur.,abdomen: , abdomen is flat, soft, nontender.  bowel sounds are active.  no masses or pulsations present.,extremities: , extremities reveal no remarkable dependent edema or varicosities.,musculoskeletal:  ,the patient is ambulatory with normal and symmetric gait.  there is adequate range of motion without significant pain or deformity.,skin: , essentially clear with no significant rash or lesions.  adequate skin turgor.,neurological: , no acute focal neurologic changes.,psychiatric:,  mental status, judgment and affect are grossly intact and normal for age.",15
"problems list:,1.  nonischemic cardiomyopathy.,2.  branch vessel coronary artery disease.,3.  congestive heart failure, nyha class iii.,4.  history of nonsustained ventricular tachycardia.,5.  hypertension.,6.  hepatitis c.,interval history: , the patient was recently hospitalized for chf exacerbation and was discharged with increased medications.  however, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  he has history of orthopnea and pnd.  he has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,review of systems: , positive for right upper quadrant pain.  he has occasional nausea, but no vomiting.  his appetite has decreased.  no joint pain, tia, seizure or syncope.  other review of systems is unremarkable.,i reviewed his past medical history, past surgical history, and family history.,social history: , he has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,allergies: , he has no known drug allergies.,medications:,  i reviewed his medication list in the chart.  he states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,physical examination:,vital signs:  pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  heent:  atraumatic and normocephalic.  no pallor, icterus or cyanosis.  neck:  supple.  jugular venous distention 5 cm above the clavicle present.  no thyromegaly.  lungs:  clear to auscultation.  no rales or rhonchi.  pulse ox was 98% on room air.  cvs:  s1 and s2 present.  s3 and s4 present.  abdomen:  soft and nontender.  liver is palpable 5 cm below the right subcostal margin.  extremities:  no clubbing or cyanosis.  a 1+ edema present.,assessment and plan:,  the patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  clinically, he is in nyha class iii.  he has some volume overload and was not unfortunately taking lasix as prescribed.  i have advised him to take lasix 40 mg p.o. b.i.d.  i also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  i advised him to continue to take toprol and lisinopril.  i have also added aldactone 25 mg p.o. daily for survival advantage.  i reinforced the idea of not using cocaine.  he states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  i encouraged him to find a primary care provider.  he will come for a bmp check in one week.  i asked him to check his blood pressure and weight.  i discussed medication changes and gave him an updated list.  i have asked him to see a gastroenterologist for hepatitis c.  at this point, his medicaid is pending.  he has no insurance and finds hard to find a primary care provider.  i will see him in one month.  he will have his fasting lipid profile, ast, and alt checked in one week.",3
"history of present illness: , the patient presents today as a consultation from dr. abc's office regarding the above.  he was seen a few weeks ago for routine followup, and he was noted for microhematuria.  due to his history of kidney stone, renal ultrasound as well as ivp was done.  he presents today for followup.  he denies any dysuria, gross hematuria or flank pain issues.  last stone episode was over a year ago.  no history of smoking.  daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,creatinine 1.0 on june 25, 2008, ua at that time was noted for 5-9 rbcs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  ivp same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  the calcification previously noted on the ureter appears to be outside the course of the ureter.  otherwise unremarkable.  this is discussed.,impression:  ,1.  a 6-mm left intrarenal stone, nonobstructing, by ultrasound and ivp.  the patient is asymptomatic.  we have discussed surgical intervention versus observation.  he indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  urine sent for culture and sensitivity.,plan: , as above.  the patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  call if any concern.  the patient is seen and evaluated by myself.",38
"preoperative diagnoses:,1.  intrauterine pregnancy at 38 weeks.,2.  malpresentation.,postoperative diagnoses:,1.  intrauterine pregnancy at 38 weeks.,2.  malpresentation.,3.  delivery of a viable male neonate.,procedure performed: , primary low transverse cervical cesarean section.,anesthesia: , spinal with astramorph.,estimated blood loss: , 300 cc.,urine output:,  80 cc of clear urine.,fluids: , 2000 cc of crystalloids.,complications: , none.,findings: , a viable male neonate in the left occiput transverse position with apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  no nuchal cord.  no meconium.  normal uterus, fallopian tubes, and ovaries.,indications: , this patient is a 21-year-old gravida 3, para 1-0-1-1 caucasian female who presented to labor and delivery in labor.  her cervix did make some cervical chains.  she did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  however, on exam unable to delineate the facial structures, but definite fetal malpresentation.  the fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  the contraction pattern was inadequate.  it was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  all the questions were answered.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  prior to this, the spinal anesthesia was administered.  the patient was then prepped and draped.  a pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  the fascia was then incised in the midline and extended laterally using mayo scissors.  the superior aspect of the rectus fascia was then grasped with ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with mayo scissors.  the superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with mayo scissors.  the rectus muscle was then separated in the midline.  the peritoneum was then identified, tented up with hemostats and entered sharply with metzenbaum scissors.  the peritoneum was then gently stretched.  the vesicouterine peritoneum was then identified, tented up with an allis and the bladder flap was created bluntly as well as using metzenbaum scissors.  the uterus was entered with the second scalpel and large transverse incision.  this was then extended in upward and lateral fashion bluntly.  the infant was then delivered atraumatically.  the nose and mouth were suctioned.  the cord was then clamped and cut.  the infant was handed off to the awaiting pediatrician.  the placenta was then manually extracted.  the uterus was exteriorized and cleared of all clots and debris.  the uterine incision was then repaired using #0 chromic in a running fashion marking a u stitch.  a second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  the uterus was then returned to the anatomical position.  the abdomen and the gutters were cleared of all clots.  again, the incision was found to be hemostatic.  the rectus muscle was then reapproximated with #2-0 vicryl in a single interrupted stitch.  the rectus fascia was then repaired with #0 vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  this was palpated and the patient was found to be without defect and intact.  the skin was then closed with staples.  the patient tolerated the procedure well.  sponge, lap, and needle counts were correct x2.  she will be followed up as an inpatient with dr. x.",37
"subjective:,  this 9-month-old hispanic male comes in today for a 9-month well-child check.  they are visiting from texas until the end of april 2004.  mom says he has been doing well since last seen.  he is up-to-date on his immunizations per her report.  she notes that he has developed some bumps on his chest that have been there for about a week.  two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  mom says he has been doing fine since then.  she has no concerns about him.,past medical history:,  significant for term vaginal delivery without complications.,medications: , none.,allergies:,  none.,social history:,  lives with parents.  there is no smoking in the household.,review of systems:,  developmentally is appropriate.  no fevers.  no other rashes.  no cough or congestion.  no vomiting or diarrhea.  eating normally.,objective:,  his weight is 16 pounds 9 ounces.  height is 26-1/4 inches.  head circumference is 44.75 cm.  pulse is 124.  respirations are 26.  temperature is 98.1 degrees.  generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,heent:  normocephalic, atraumatic.  anterior fontanel is soft and flat.  tympanic membranes are clear bilaterally.  conjunctivae are clear.  pupils equal, round and reactive to light.  nares without turbinate edema.  oropharynx is nonerythematous.,neck:  supple, without lymphadenopathy, thyromegaly, carotid bruit, or jvd.,chest:  clear to auscultation bilaterally.,cardiovascular:  regular rate and rhythm, without murmur.,abdomen:  soft, nontender, nondistended, normoactive bowel sounds.  no masses or organomegaly to palpation.,gu:  normal male external genitalia.  uncircumcised penis.  bilaterally descended testes.  femoral pulses 2/4.,extremities:  moves all four extremities equally.  minimal tibial torsion.,skin:  without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,assessment/plan:,1.  well-child check.  is doing well.  will recommend a followup well-child check at 1 year of age and immunizations at that time.  discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with mom.  she is given a parenting guide handout.,2.  molluscum contagiosum.  described the viral etiology of these.  told her they are self limited, and we will continue to monitor at this time.,3.  left otitis media, resolved.  continue to monitor.  we will plan on following up in three months if they are still in the area, or p.r.n.",5
"history:,  reason for icu followup today is acute anemia secondary to upper gi bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units prbcs with egd performed earlier today by dr. x of gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.  please see dictated icu transfer note yesterday detailing the need for emergent transfer transfusion and egd in this patient.  over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value.  he also underwent egd earlier today with dr. x.  i have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding.  dr. x recommended to increase the doses of his proton pump inhibitor and to avoid nsaids in the future.  the patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the icu.  he is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.,physical examination,vital signs:  blood pressure is 100/54, heart rate 80 and temperature 98.8.  is and os negative fluid balance of 1.4 liters in the last 24 hours.,general:  this is a somnolent 68-year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough.  pallor is improved.,eyes:  conjunctivae are now pink.,ent:  oropharynx is clear.,cardiovascular:  reveals distant heart tones with regular rate and rhythm.,lungs:  have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.,abdomen:  soft and nontender with no organomegaly appreciated.,extremities:  showed no clubbing, cyanosis or edema.  capillary refill time is now normal in the fingertips.,neurological:  cranial nerves ii through xii are grossly intact with no focal neurological deficits.,laboratory data:,  laboratories drawn at 1449 today, wbc 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000.  this is up from 8.6 and 24.7.  platelets are stable.  sodium is 134, potassium 4.0, chloride 101, bicarb 26, bun 19, creatinine 1.0, glucose 73, calcium 8.4, inr 0.96, iron 13%, saturations 4%, tibc 312, tsh 0.74, cea elevated at 8.6, ferritin 27.5 and occult blood positive.  egd, final results pending per dr. x's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.,impression/plan,1.  melena secondary to ulcerative esophagitis.  we will continue to monitor the patient overnight to ensure there is no further bleeding.  if there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.,2.  chronic obstructive pulmonary disease exacerbation.  the patient is doing well, taking po.  we will continue him on his oral omnicef and azithromycin and continuing breathing treatments.  we will add guaifenesin and n-acetyl-cysteine in a hope to mobilize some of his secretions.  this does appear to be improving.  his white count is normalized and i am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.,3.  elevated cea.  the patient will need colonoscopy on an outpatient basis.  he has refused this today.  we would like to encourage him to do so.  of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion.  similarly, i am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated cea and risk factors.,4.  anemia, normochromic normocytic with low total iron binding capacity.  this appears to be anemia of chronic disease.  however, this is likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin c, folate and b12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding.  total critical care time spent today discussing the case with dr. x, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.",12
"preoperative diagnoses: , left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,postoperative diagnoses:,  left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,procedures:  ,1.  open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  closed reduction casting of the right forearm.,anesthesia: , surgery performed under general anesthesia.  local anesthetic was 10 ml of 0.5% marcaine.,tourniquet time: , on the left was 29 minutes.,complications:  ,there were no intraoperative complications.,drains: , none.,specimens: , none.,history and physical:  ,the patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  the patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  after the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  at that same time, the patient's mildly angulated radial shaft fracture will be reduced.  this was explained to the father.  the risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  all questions were answered.  the father agreed to the above plan.,procedure in detail: , the patient was taken to the operating room and placed supine on the operating room table.  general anesthesia was then administered.  the patient received ancef preoperatively.  the left upper extremity was then prepped and draped in the standard surgical fashion.  attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  it was decided at this time that she would need open reduction.  the arm was wrapped in esmarch prior to inflation of the tourniquet to 250 mmhg.  the esmarch was then removed.  an incision was then made.  care was taken to avoid any injury to the ulnar nerve.  the medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  this was easily removed.  the ulnar nerve was also identified, and appeared to be intact.  the medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  after fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  the wound was then irrigated with normal saline and closed using 2-0 vicryl and 4-0 monocryl.  the wound was clean and dry, dressed with steri-strips and xeroform.  the area was infiltrated with 0.5% marcaine.  the patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  the tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  the final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  the patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,postoperative plan: , the patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  the father was made aware of the intraoperative findings.  all questions answered.",26
"preoperative diagnosis: , inguinal hernia.,postoperative diagnosis: , direct inguinal hernia.,procedure performed:,  rutkow direct inguinal herniorrhaphy.,anesthesia: , general endotracheal.,description of procedure:  ,after informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  general endotracheal anesthesia was induced without incident.  preoperative antibiotics were given for prophylaxis against surgical infection.  the patient was prepped and draped in the usual sterile fashion.,a standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of metzenbaum scissors and bovie electrocautery.  the external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  the external oblique was then incised with a scalpel and this incision was carried out to the external ring using metzenbaum scissors.  having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a penrose drain was placed around the cord structures at the level of the pubic tubercle.  this penrose drain was then used to retract the cord structures as needed.  adherent cremasteric muscle was dissected free from the cord using bovie electrocautery.,the cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  the hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  this was dissected back to the hernia opening.  the hernia was inverted back into the abdominal cavity and a large perfix plug inserted into the ring.  the plug was secured to the ring by interrupted 2-0 prolene sutures.,the perfix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 prolene sutures.  by reinforcing the floor with the onlay patch, a new internal ring was thus formed.,the penrose drain was removed.  the wound was then irrigated using sterile saline, and hemostasis was obtained using bovie electrocautery.  the incision in the external oblique was approximated using a 2-0 vicryl in a running fashion, thus reforming the external ring.  the skin incision was approximated with 4-0 monocryl in a subcuticular fashion.  the skin was prepped with benzoin, and steri-strips were applied.  all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.",38