Datasets:

argilla

/

medical-domain

like 22

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

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

{ "text_length": 5749 }

{ "text": "COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm." }

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

{ "text_length": 4480 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1. Hallux rigidus, left foot.,2. Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1. Austin/Youngswick bunionectomy with Biopro implant.,2. Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint. The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time. The patient desires surgical treatment.,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 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block. 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 then inflated to 250 mmHg. The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint. Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon. The incision was then deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was undermined medially, off of the joint capsule. A dorsal linear capsular incision was then made. Care was taken to identify and preserve the extensor hallucis longus tendon. The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx. There was noted to be a significant degenerative joint disease. There was little to no remaining healthy articular cartilage left on the head of the first metatarsal. There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx. A sagittal saw was then used to resect the base of the proximal phalanx. Care was taken to ensure that the resection was parallel to the nail. After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact. The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal. The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp. The sizers were then inserted for the Biopro implant. A large was noted to be of the best size. There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx. Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base. A small bar drill was then used to pre-drill for the Biopro sizer. The bone was noted to be significantly hardened. The sizer was placed and a large Biopro was deemed to be the correct size implant. The sizer was removed and bar drill was then again used to ream the medullary canal. The hand reamer with a Biopro set was then used to complete the process. The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit. There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal. A long dorsal arm Austin osteotomy was then created. A second osteotomy was then created just plantar and parallel to the first osteotomy site. The wedge was then removed in toto. The area was feathered to ensure high compression of the osteotomy site. The head was noted to be in a more plantar flexed position. The capital fragment was then temporarily fixated with two 0.45 K-wires. A 2.7 x 16 mm screw was then inserted in the standard AO fashion. A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion. With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash. A screw driver was then used to check and ensure screw tightness. The area was then flushed with copious amounts of sterile saline. Subchondral drilling was performed with a 1.5 drill bit. The area was then flushed with copious amounts of sterile saline. Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl. Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban. A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia. 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. The patient was transported to PACU with vital signs stable and vascular status intact to the right foot. The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q. 4-6h. p.o. p.r.n. pain. The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema. The patient is to follow up with Dr. X in his office as directed." }

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

{ "text_length": 5807 }

{ "text": "CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY: ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY: ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily. The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:, Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:, The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use.,PHYSICAL EXAMINATION: ,GENERAL: This is a 76-year-old female, well nourished. VITAL SIGNS: On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20. HEENT: Anicteric sclerae. Conjunctivae pink. Throat was clear. Mucosal membranes were dry. CHEST: Coarse breath sounds bilaterally at the bases. CARDIAC: S1 and S2. No murmurs, rubs or gallops. No evidence of carotid bruits. ABDOMEN: Positive bowel sounds, presence of soreness on examination in the abdomen on palpation. There is no rebound or guarding. EXTREMITIES: No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes. There is no evidence of effusion or consolidation. Degenerative changes were seen in the shoulder. The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern. Urinalysis showed no evidence of infection as well as her influenza A&B were negative. Preliminary blood cultures have been with no growth to date status post 48 hours. The patient was started on cefepime 1 g IV q.12h. and given IV hydration. She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol. In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis. Currently today, she feels much improved with still only a mild cough. The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18. Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:, Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily. Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:, To follow a low-salt diet.,ACTIVITY:, As tolerated.,FOLLOWUP: ,To follow up with Dr. ABC in two weeks." }

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

{ "text_length": 3504 }

{ "text": "ADMITTING DIAGNOSIS:, Aftercare of multiple trauma from an motor vehicle accident.,DISCHARGE DIAGNOSES:,1. Aftercare following surgery for injury and trauma.,2. Decubitus ulcer, lower back.,3. Alcohol induced persisting dementia.,4. Anemia.,5. Hypokalemia.,6. Aftercare healing traumatic fracture of the lower arm.,7. Alcohol abuse, not otherwise specified.,8. Aftercare healing traumatic lower leg fracture.,9. Open wound of the scalp.,10. Cervical disk displacement with myelopathy.,11. Episodic mood disorder.,12. Anxiety disorder.,13. Nervousness.,14. Psychosis.,15. Generalized pain.,16. Insomnia.,17. Pain in joint pelvic region/thigh.,18. Motor vehicle traffic accident, not otherwise specified.,PRINCIPAL PROCEDURES:, None.,HISTORY OF PRESENT ILLNESS: , As per Dr. X without any changes or corrections.,HOSPITAL COURSE: ,This is a 50-year-old male, who is initially transferred from Medical Center after treatment for multiple fractures after a motor vehicle accident. He had a left tibial plateau fracture, right forearm fracture with ORIF, head laceration, and initially some symptoms of head injury. When he was initially transferred to HealthSouth, he was status post ORIF for his right forearm. He had a brace placed in the left leg for his left tibial plateau fracture. He was confused initially and initially started on rehab. He was diagnosed with some acute psychosis and thought problems likely related to his alcohol abuse history. He did well from orthopedic standpoint. He did have a small sacral decubitus ulcer, which was well controlled with the wound care team and healed quite nicely. He did have some anemia initially and he had dropped down in to the low 9, but he was 9.2 with his lowest on 06/11/2008, which had responded well to iron treatment and by the time of discharge, he was lower at 11.0. He made slow progress from therapy. His confusion gradually cleared. He did have some problems with insomnia and was placed on Seroquel to help with both of his moods and other issues and he did quite well with this. He did require some Ativan for agitation. He was on chronic pain medications as an outpatient. His medications were adjusted here and he did well with this as well. The patient was followed throughout his entire stay with case management and discussions were made with them and the psychologist concerning the placement upon discharge to an acute alcohol rehab facility; however, the patient refused throughout this entire stay. We did have orthopedic followup. He was taken out of his right leg brace the week of 06/16/2008. He did well with therapy. Overall, he was doing much and much better. He had progressed with the therapy to the point where that he was comfortable to go home and receive outpatient therapy and follow up with his primary care physician. On 06/20/2008, with all parties in agreement, the patient was discharged to home in stable condition.,At the time of discharge, the patient's ambulatory status was much better. He was using a wheeled walker. He was able to bear weight on his left leg. His pain level had been well controlled and his moods had improved dramatically. He was no longer having any signs of agitation or confusion and he seemed to be at a stable baseline. His anemia had resolved almost completely and he was doing quite well. ,MEDICATIONS: , On discharge included:,1. Calcium with vitamin D 1 tablet twice a day.,2. Ferrous sulfate 325 mg t.i.d.,3. Multivitamin 1 daily.,4. He was on nicotine patch 21 mg per 24 hour.,5. He was on Seroquel 25 mg at bedtime.,6. He was on Xenaderm for his sacral pressure ulcer.,7. He was on Vicodin p.r.n. for pain.,8. Ativan 1 mg b.i.d. for anxiety and otherwise he is doing quite well.,The patient was told to follow up with his orthopedist Dr. Y and also with his primary care physician upon discharge." }

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

{ "text_length": 3880 }

{ "text": "PROCEDURES:,1. Right frontal craniotomy with resection of right medial frontal brain tumor.,2. Stereotactic image-guided neuronavigation for resection of tumor.,3. Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE: ,The patient is a 71-year-old female with a history of left-sided weakness and headaches. She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago. An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor. After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube. She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor. We marked external landmarks. Then we shaved the head over the right medial frontal area. This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline. This was opened and hemostasis obtained using Raney clips. The skin flap was retracted medially. Two burr holes were made and were carefully connected. One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap. Hemostasis was obtained. Using the neuronavigation, we identified where the tumor was. The dura was then opened based on a horseshoe flap based on the medial sinus. We retracted this medially and carefully identified the brain. The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor. Subsequently, we entered the tumor. The tumor itself was extremely hard. Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case. We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor. Then we collapsed the tumor on itself and removed it entirely. In this fashion, microdissection and magnification resection of the tumor was carried out. We resected the entire tumor. Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam. We also lined the cavity with Surgicel. The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion. Surgicel was placed over the dural closure. The bone flap was repositioned and held in place using CranioFIX cranial fixators. The galea was re-approximated and the skin was closed with staples. The wound was dressed. The patient was returned to the intensive care unit. She was awake and moving extremities well. No apparent complications were noted. Needle and sponge counts were listed as correct at the end of the procedure. Estimated intraoperative blood loss was approximately 150 mL and none was replaced." }

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

{ "text_length": 4117 }

{ "text": "HISTORY:, The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss. The patient reports that she has been having history of recurrent sinus infection, averages about three times per year. During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well. The patient does note that she has been having hearing loss. This is particular prominent in the right ear now for the past three to four years. She does note popping after blowing the nose. Occasionally, the hearing will improve and then it plugs back up again. She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her. She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement. She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage. She feels that she is having a hard time swallowing at times as well. She has complained of a lump sensation in the throat that tends to come and go. She denies any cough, no hemoptysis, no weight change. No night sweats, fever or chills has been noted. She is having at this time no complaints of tinnitus or vertigo. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS: ,ALLERGY/IMMUNOLOGIC: History of seasonal allergies. She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR: Pertinent for hypercholesterolemia.,PULMONARY: She has a history of cough, wheezing.,GASTROINTESTINAL: Negative.,GENITOURINARY: Negative.,NEUROLOGIC: She has had a history of TIAs in the past.,VISUAL: She does have history of vision change, wears glasses.,DERMATOLOGIC: Negative.,ENDOCRINE: Negative.,MUSCULOSKELETAL: History of joint pain and bursitis.,CONSTITUTIONAL: She has a history of chronic fatigue.,ENT: She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC: History of anxiety, depression.,HEMATOLOGIC: Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984. She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension. Brother, colon CA. Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily. She takes vitamins one a day. She is on Zocor, Desyrel, Flonase, and Xanax. She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling. She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single. She is unemployed at this time. She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL: The patient is an alert, cooperative, well-developed 51-year-old female. She has a normal-sounding voice and good memory.,HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.,CARDIOVASCULAR: Heart regular rate and rhythm without murmur.,RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES: Extraocular muscles were tested and within normal limits.,EARS: Right ear, the external ear is normal. The ear canal is clean and dry. The drum is intact. She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss. Left ear, the external ear is normal. The ear canal is clean and dry. The drum is intact and mobile with grossly normal hearing. The audiogram does reveal normal hearing in the left ear. She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally. Tympanograms, there was no adequate seal obtained on the right side. She has a normal type A tympanogram, left side.,NASAL: Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.,DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms. Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted. The nasopharynx does reveal moderate adenoid pad within this midline. It is nonulcerated. The larynx revealed both cords to be normal. She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION: ,1. Persistent dysphagia. I think secondary most likely to the persistent postnasal drainage.,2. Deviated nasal septum.,3. Inferior turbinate hypertrophy.,4. Chronic rhinitis.,5. Conductive hearing loss, right ear with a history of cholesteatoma of the right ear." }

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

{ "text_length": 6154 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice. Preparation was good, although there was some residual material in the cecum that was difficult to clear completely. The mucosa was normal throughout the colon. No polyps or other lesions were identified, and no blood was noted. Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation. A retroflex view of the anorectal junction showed no hemorrhoids. The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1. Diverticulosis in the sigmoid.,2. Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1. Follow up with Dr. X as needed.,2. Screening colonoscopy in 2 years.,3. Additional evaluation for other causes of anemia may be appropriate." }

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

{ "text_length": 1085 }

{ "text": "REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding. He states that he had some stomach discomfort in the last 4 weeks. He has had some physical therapy for his lower back secondary to pain after hernia repair. He states that the pain worsened after this. He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal. He denies any dysuria. He denies any hematemesis. He denies any pleuritic chest pain. He denies any hemoptysis.,PAST MEDICAL HISTORY:,1. History of bilateral hernia repair by Dr. X in 8/2008.,2. History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1. Cipro.,2. Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , 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 afebrile. Pulse 117, respirations 18, and blood pressure 117/55. Saturating 98% on room air.,GENERAL: The patient is alert and oriented x3.,HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear without exudates.,NECK: Supple. No thyromegaly. No jugular venous distention.,HEART: Tachycardic. Regular rhythm without murmurs, rubs or gallops.,LUNGS: Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN: Positive bowel sounds. Soft and nontender with no guarding.,EXTREMITIES: No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC: Nonfocal.,LABORATORY STUDIES:, Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils. EKG shows sinus tachycardia.,PROBLEM LIST:,1. Colitis.,2. Sepsis.,3. Rectal bleeding.,RECOMMENDATIONS:,1. GI consult with Dr. Y's group.,2. Continue Levaquin and Flagyl.,3. IV fluids.,4. Send for fecal WBCs, O&P, and C. diff.,5. CT of the abdomen and pelvis to rule out abdominal pathology.,6. PPI for PUD prophylaxis." }

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

{ "text_length": 2275 }

{ "text": "S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1. Onychocryptosis.," }

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

{ "text_length": 488 }

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

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

{ "text_length": 3392 }

{ "text": "OPERATIVE PROCEDURE,1. Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2. Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery. Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:, The patient was brought to the operating room, placed in supine position. Adequate general endotracheal anesthesia was induced. Appropriate monitoring lines were placed. The chest, abdomen and legs were prepped and draped in a sterile fashion. The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution. The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped. A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze. The sternum was closed. A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma. The deep fascia was divided. The facial vein was divided between clamps and tied with 2-0 silk. The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves. The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk. Shunts were prepared. A patch was prepared. Heparin 50 mg was given IV. Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery. Distal internal was held with a forceps. Internal carotid artery was opened with 11-blade. Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond. The shunt was placed and proximal and distal snares were tightened. Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external. All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line. Suture line was completed and the neck was packed.,The pericardium was opened. A pericardial cradle was created. The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula. A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet. An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted. The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg. This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus. The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture. The vein was cut to length. Antegrade and retrograde cold blood potassium cardioplegia was given. The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein. The vein was cut to length. The mammary was clipped distally, divided and spatulated for anastomosis. Antegrade and retrograde cold blood potassium cardioplegia was given. The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture. Warm blood potassium cardioplegia was given, and the cross-clamp was removed. A partial-occlusion clamp was placed. Two aortotomies were made. The veins were cut to fit these and sutured in place with running 5-0 Prolene suture. The partial- occlusion clamp was removed. All anastomoses were inspected and noted to be patent and dry. Atrial and ventricular pacing wires were placed. Ventilation was commenced. The patient was fully warmed. The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion. Protamine was given. Good hemostasis was noted. A single mediastinal chest tube and bilateral pleural Blake drains were placed. The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch." }

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

{ "text_length": 5203 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1. Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2. Spondylolisthesis, which is unstable at L4-L5.,3. Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1. Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2. Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3. Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft. All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS: ,Approximately 1000 cc.,CELL SAVER RETURNED: ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain. He had previous lumbar laminectomy at L4-L5. He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable. He is suffering from neurogenic claudication. He was unresponsive to extensive conservative treatment. He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia. He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded. His lumbar spine was then sterilely prepped and draped in the usual fashion. A previous midline incision was extended from approximate level of L3 to S1. This was in the midline. Skin and subcutaneous tissue were debrided sharply. Electrocautery provided hemostasis. ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia. The lumbar fascia was identified and split in the midline. Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1. Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4. Once this was completed, a self-retaining retractor was then placed. With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable. These were readily mobile with digital palpation. A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1. This bone was morcellized and placed on the back table for utilization for bone grafting. The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1. Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained. Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1. The microscope was utilized during this portion of procedure for visualization. There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure. Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5. Once this was identified, foraminotomies were created to allow additional mobility. The wound was then copiously irrigated with antibiotic solution and suctioned dry. Working type screws, provisional titanium screws were then placed at L4-l5. This was to allow distraction and reduction of the spondylolisthesis. These were placed in the pedicles of L4 and L5 under direct intensification. The position of the screws were visualized, both AP and lateral images. They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5. This allowed for additional decompression of the L5 and L4 nerve roots. Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed. Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval. This was taken in sequence up to a 13 mm space. This was then reduced to a 11 mm as it was much more anatomic in nature. Once this was completed, the spacers were then placed on the left side and distraction obtained. Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally. Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried. A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft. There were impacted at the interspace of L4-L5 under direct image intensification. Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried. The provisional screws and plates were removed. This allowed for additional compression along L4-L5 with the cage instrumentation. Permanent screws were then placed at L4, L5, and S1 bilaterally. This was performed under direct image intensification. The position was verified in both AP and lateral images. Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone. The wound was then copiously irrigated with antibiotic solution and suction dried. The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally. A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1. Appropriate cross connecters were applied and the construct was placed over the pedicle screws. They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra. Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory. All connections were tightened and retightened in Torque 2 specifications. The wound was then copiously irrigated with antibiotic solution and suction dried. The dura was inspected and noted to be free of tension. At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors. An 8-inch Hemovac drain was placed exiting the wound. The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin. The remainder of the Hemovac was assembled. Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape. He was turned and taken to the recovery room in apparent satisfactory condition. Expected surgical prognosis remains guarded." }

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

{ "text_length": 7461 }

{ "text": "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," }

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

{ "text_length": 411 }

{ "text": "PREOPERATIVE DIAGNOSES:, Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES: ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:, Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007. The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:, The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department. The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation. Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision. The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed. The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection. Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end. A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. Adequate hemostasis was noted. This tube was placed back in its anatomic position. The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position. The peritoneum as well as fascia was reapproximated with 0-Vicryl. The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch. Pressure dressings were applied. Marcaine 10 mL was used prior to making an incision. Sterile dressing was applied. The large mole-like lesion was grasped with Allis. It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied. Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition." }

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

{ "text_length": 2821 }

{ "text": "REASON FOR CONSULTATION: , New murmur with bacteremia.,HISTORY OF PRESENT ILLNESS:, The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently.,PAST MEDICAL HISTORY:, Significant for diabetes, hypertension, and TIA.,MEDICATIONS: , Include:,1. Acidophilus supplement.,2. Cholestyramine.,3. Creon 20 three times daily.,4. Diovan 160 mg twice daily.,6. Lantus 10 daily.,7. Norvasc 5 mg daily.,8. NovoLog 70/30, 10 units at 12 noon daily.,9. Pamelor 15 mL every evening.,10. Vitamin D3 one tablet weekly.,ALLERGIES: , THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN.,FAMILY HISTORY: ,The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF.,SOCIAL HISTORY: , The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena.,REVIEW OF SYSTEMS: , The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative.,PHYSICAL EXAMINATION,GENERAL: An elderly Caucasian female, awake and alert, and in no distress.,VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%.,HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist.,CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze.,CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift.,ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits.,EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+.,NEUROLOGIC: She exhibits no focal motor or sensory findings.,LABORATORY DATA: , The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10.,DIAGNOSTIC IMAGING: , The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.,EKG shows normal sinus rhythm. There are no acute ST-T changes.,ASSESSMENT: , This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia.,PLAN: ,The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive." }

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

{ "text_length": 3775 }

{ "text": "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." }

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

{ "text_length": 946 }

{ "text": "SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion." }

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

{ "text_length": 2489 }

{ "text": "CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0). Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:," }

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

{ "text_length": 2242 }

{ "text": "REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1. Arthritis of the right knee.,2. Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.,ALLERGIES: , MORPHINE.,HISTORY OF PRESENT COMPLAINT: , This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday. The patient is admitted today to the surgical floor for postoperative management. The patient tolerated the procedure well.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No fever, chills, or malaise.,ENT: Unremarkable.,RESPIRATORY: The patient denies shortness of breath, cough, or wheezing.,CARDIOVASCULAR: No known heart problems. No orthopnea, palpitations, syncopal episode, or pedal swelling.,GASTROINTESTINAL: She denies nausea or vomiting. No history of GI bleed.,GENITOURINARY: No dysuria, no hematuria.,ENDOCRINE: Negative for diabetes or thyroid problems.,NEUROLOGICAL: No history of seizure or TIA. Cognitive function is intact.,SOCIAL HISTORY: ,The patient does not smoke. She consumes alcohol moderately.,FAMILY HISTORY: ,Positive for cancer.,PHYSICAL EXAMINATION:,GENERAL: This is an 84-year-old lady who looks young for her age.,VITAL SIGNS: Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air. She is afebrile.,HEAD AND NECK: Face is symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses.,CHEST: Clear to auscultation. No wheezing. No crepitations.,CARDIOVASCULAR: First and second heart sounds were heard. No murmur is appreciated.,ABDOMEN: Soft and nontender. Bowel sounds are positive.,EXTREMITIES: There is no pedal swelling.,LABORATORY DATA: ,Hemoglobin has dropped from 12.6 to 10.2. Hematocrit is 30. Glucose is 125. BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.,ASSESSMENT AND PLAN:,1. Right knee arthritis status post right total knee replacement. The patient tolerated the procedure well.,2. Anemia due to stated operative blood loss, would not require transfusion at this point.,3. Hypertension, under control. Continue current home medications.,4. Deep vein thrombosis risk, prophylaxis as per surgeon.,5. Gastrointestinal prophylaxis.,6. Debility. Continue physical therapy and occupational therapy." }

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

{ "text_length": 2537 }

{ "text": "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." }

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

{ "text_length": 1513 }

{ "text": "CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a \"high grade stenosis\" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled \"world\" backward, as \"dlow.\",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy." }

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

{ "text_length": 2956 }

{ "text": "CHIEF COMPLAINT:, Decreased ability to perform daily living activities secondary to right knee surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old white female status post right total knee replacement secondary to degenerative joint disease performed by Dr. A at ABCD Hospital on 08/21/2007. The patient was transfused with 2 units of autologous blood postoperatively. She received DVT prophylaxis with a combination of Coumadin, Lovenox, SCD boots, and TED stockings. The remainder of her postoperative course was uneventful. She was discharged on 08/24/2007 from ABCD Hospital and admitted to the transitional care unit at XYZ Services for evaluation and rehabilitation. The patient reports that her last bowel movement was on 08/24/2007 just prior to her discharge from ABCD Hospital. She denies any urological symptoms such as dysuria, incomplete bladder emptying or other voiding difficulties. She reports having some right knee pain, which is most intense at a \"certain position.\" The patient is unable to elaborate on which \"certain position\" causes her the most discomfort.,ALLERGIES:, NKDA.,PAST MEDICAL HISTORY: , Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.,MEDICATIONS:, On transfer, Celebrex, Coumadin, Colace, Synthroid, Lovenox, Percocet, Toprol XL, niacin, and trazodone.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 96.5, blood pressure 127/72, pulse 70, respiratory rate 20, 95% O2 saturation on room air.,GENERAL: No acute distress at the time of the exam except as mentioned above complains of right knee pain at \"certain position.\",HEENT: Normocephalic. Sclerae nonicteric. EOMI. Dentition in good repair. Tongue is in midline with no evidence of thrush.,NECK: No thyroid enlargement. Trachea is midline.,LUNGS: Clear to auscultation.,HEART: Regular rate and rhythm. Normal S1 and S2.,ABDOMEN: Soft, nontender, and nondistended. No organomegaly.,EXTREMITIES: The right knee incision is intact. Steri-Strips are in place. There is some diffuse right knee edema and some limited ecchymosis as well. No calf tenderness bilaterally. Pedal pulses are palpable bilaterally.,MENTAL STATUS: The patient appears slightly anxious during the interview and exam, but she was alert and oriented.,HOSPITAL COURSE: , As mentioned above, the patient was admitted on 08/24/2007 to the Transitional Care Unit at XYZ Services for evaluation and rehabilitation. She was seen in consultation by Physical Therapy and Occupational Therapy and had begun her rehabilitation till recovery. The patient had been properly instructed regarding using the CPM machine and she had been instructed as well to limit each CPM session to two hours. Very early in her hospitalization, the patient enthusiastically used the CPM much longer than two hours and consequently had increased right knee pain. She remarked that she had a better degree of flexibility, but she did report an increased need for pain management. Additionally, she required Ativan and at one point scheduled the doses of Ativan to treat her known history of anxiety disorder. On the fourth hospital day, she was noted to have some rashes about the right upper extremity and right side of her abdomen. The patient reported that this rash was itchy. She reports that she had been doing quite a bit of gardening just prior to surgery and this was most likely contact dermatitis, most likely due to her gardening activities preoperatively. She was treated with betamethasone cream applied to the rash b.i.d. The patient's therapy had progressed and she continued to make a good progress. At one point, the patient reported some insomnia due to right knee pain. She was switched from Percocet to oxycodone SR 20 mg b.i.d. and she had good pain control with this using the Percocet only for breakthrough pain. The DVT prophylaxis was maintained with Lovenox 40 mg subcu daily until the INR was greater than 1.7 and it was discontinued on 08/30/2007 when the INR was 1.92 within therapeutic range. The Coumadin was adjusted accordingly according to the INRs during her hospital course. Early in the hospital course, the patient had reported right calf tenderness and a venous Doppler study obtained on 08/27/2007 showed no DVT bilaterally. Initial laboratory data includes a UA on 08/28/2007, which was negative. Additionally, CBC showed a white count of 6.3, hemoglobin was 12.1, hematocrit was 35.3, and platelets were 278,000. Chemistries were within normal limits. Creatinine was 0.8, BUN was 8, anion gap was slightly decreased at 5, fasting glucose was 102. The remainder of chemistries was unremarkable. The patient continued to make great progress with her therapies so much so that we are anticipating her discharge on Monday, 09/03/2007.,DISCHARGE DIAGNOSES:,1. Status post right total knee replacement secondary to degenerative joint disease performed on 08/21/2007.,2. Anxiety disorder.,3. Insomnia secondary to pain and anxiety postoperatively.,4. Postoperative constipation.,5. Contact dermatitis secondary to preoperative gardening activities.,6. Hypertension.,7. Hypothyroidism.,8. Gastroesophageal reflux disease.,9. Morton neuroma of the feet bilaterally.,10. Distant history of migraine headaches.,INSTRUCTIONS GIVEN TO THE PATIENT AT THE TIME OF DISCHARGE: , The patient is advised to continue taking the following medications: Celebrex 200 mg daily, for one month, Colace 100 mg b.i.d. for one month, Protonix 40 mg b.i.d. for one month, Synthroid 137 mcg daily, Diprosone cream 0.05% cream b.i.d. to the right arm and right abdomen, oxycodone SR 20 mg p.o. q.12h. for five days, then decrease to oxycodone SR 10 mg p.o. q.12h. for five days, Percocet 5/325 mg one to two tablets q.6h. to be used p.r.n. for breakthrough pain, trazodone 50 mg p.o. at bedtime p.r.n. for two weeks, Ativan 0.25 mg b.i.d. for two weeks, and Toprol-XL 50 mg daily. The patient will also take Coumadin and the dose will be adjusted according to the INRs, which will be obtained every Monday and Thursday with results being sent to Dr. A and his fax number is 831-5926. At the present time, the patient is taking Coumadin 7 mg daily. She will remain on Coumadin for 30 days. An INR is to be obtained on 09/03/2007 and should the Coumadin dose be changed, an addendum will be dictated to accompany this discharge summary. Finally, the patient has a followup appointment with Dr. A on 09/21/2007 at noon at his office. The patient is encouraged to follow up with her primary care physician, Dr. B. As mentioned above, the patient will be discharged on 09/03/2007 in stable and improved condition since she is status post right total knee replacement and has made good progress with her therapies and rehabilitation." }

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

{ "text_length": 6886 }

{ "text": "HISTORY: , A is a young lady, who came here with a diagnosis of seizure disorder and history of Henoch-Schonlein purpura with persistent proteinuria. A was worked up for collagen vascular diseases and is here to find out the results. Also was recommended to take 7.5 mg of Mobic every day for her joint pains. She states that she continues with some joint pain and feeling tired all the time. Mother states that also her seizure has continued without any control so far. She is having some studies in the next few days. She is mostly stiff on her legs, neck, and also on her hands. The rest of the review of systems is in the chart.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Temperature today is 99.2 degrees Fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,HEENT: She has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations. Pupils are reactive to accommodation. Funduscopic examination is within normal limits.,NECK: No neck masses.,CHEST: Clear to auscultation.,HEART: Regular rhythm with no murmur.,ABDOMEN: Soft, nontender with no visceromegaly.,SKIN: No rashes today.,MUSCULOSKELETAL: Examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,LABORATORY DATA: , Laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin D levels.,ASSESSMENT: , This is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin D. She also has chronic proteinuria and seizure disorder. My recommendation is to start her on vitamin D and calcium supplements, and also increase the Mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking. We are going to refer her to physical therapy and see her back in 2 months for followup. The plan was discussed with A and her parents and they have no further questions." }

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

{ "text_length": 2231 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,OPERATION:, Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1. Prostatism.,2. Bladder calculus.,ANESTHESIA: ,General.,INDICATIONS:, This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. The cystoscopy showed a large bladder calculus, short but obstructing prostate. He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA: ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia. Prepped and draped in the dorsal lithotomy position. A 27-French Olympus rectoscope was passed via the urethra into the bladder. The bladder, prostate, and urethra were inspected. He had an obstructing prostate. He had marked catheter reaction in his bladder. He had a lot of villous changes, impossible to tell from frank tumor. He had a huge bladder calculus. It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. There was still stone left at the end of the procedure. Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB. We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP. We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient." }

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

{ "text_length": 2081 }

{ "text": "REPORT:, The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally. Little activity in the beta range is noted. Waves of 4-7 cycle/second of low amplitude were occasionally noted. Abundant movements and technical artifacts are noted throughout this tracing. Hyperventilation was not performed. Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:, The electroencephalogram is essentially normal." }

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

{ "text_length": 455 }

{ "text": "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." }

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

{ "text_length": 4017 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:, Bilateral vasectomy.,ANESTHESIA:, Local.,INDICATIONS FOR PROCEDURE: ,A gentleman who is here today requesting voluntary sterility. Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table. Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. A small incision was made in the right hemiscrotum. The vas deferens was grasped with a vas clamp. Next, the vas deferens was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum. The vas deferens was isolated. It was skeletonized. It was clipped proximally and distally twice. The cut edges were fulgurated. Meticulous hemostasis was maintained. Then, 4-0 chromic was used to close the scrotal skin. A jockstrap and sterile dressing were applied at the end of the case. Sponge, needle, and instruments counts were correct." }

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

{ "text_length": 1545 }

{ "text": "REVIEW OF SYSTEMS:,CONSTITUTIONAL: Patient denies fevers, chills, sweats and weight changes.,EYES: Patient denies any visual symptoms.,EARS, NOSE, AND THROAT: No difficulties with hearing. No symptoms of rhinitis or sore throat.,CARDIOVASCULAR: Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY: No dyspnea on exertion, no wheezing or cough.,GI: No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU: No urinary hesitancy or dribbling. No nocturia or urinary frequency. No abnormal urethral discharge.,MUSCULOSKELETAL: No myalgias or arthralgias.,NEUROLOGIC: No chronic headaches, no seizures. Patient denies numbness, tingling or weakness.,PSYCHIATRIC: Patient denies problems with mood disturbance. No problems with anxiety.,ENDOCRINE: No excessive urination or excessive thirst.,DERMATOLOGIC: Patient denies any rashes or skin changes." }

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

{ "text_length": 937 }

{ "text": "PREOPERATIVE DIAGNOSES:, Bilateral inguinal hernias with bilateral hydroceles after right inguinal hernia repair, cerebral palsy, asthma, seizure disorder, developmental delay, and gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSES: , Left inguinal hernia, bilateral hydroceles, and right torsed appendix testis.,PROCEDURE: , Right inguinal exploration, left inguinal hernia repair, bilateral hydrocele repair, and excision of right appendix testis.,FLUIDS RECEIVED: ,700 mL of crystalloid.,ESTIMATED BLOOD LOSS: ,10 mL.,SPECIMENS:, Tissue sent to pathology is calcified right appendix testis.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS: ,Sponge and needle counts were correct x2.,ANESTHESIA: , General inhalational anesthetic and 0.25% Marcaine ilioinguinal nerve block, 30 mL given per surgeon.,INDICATIONS FOR OPERATION: ,The patient is a 14-1/2-year-old boy with multiple medical problems, primarily due to cerebral palsy, asthma, seizures, gastroesophageal reflux disease, and developmental delay. He had a hernia repair done on the right in the past, but developed a new hernia on the right and a smaller on the left. The plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then placed in the supine position. IV antibiotics were given. He was then sterilely prepped and draped. A right inguinal incision was made in the previous incisional site with a 15-blade knife, extended down through the subcutaneous tissue and Scarpa fascia with electrocautery. Electrocautery was used for hemostasis.,The external oblique fascia was then visualized and incised. There was a moderate amount of scar tissue noted, but we were able to incise that and go down into the right inguinal canal. Upon dissection there, we did not find any hernias; however, he did have a fairly sizable hydrocele. We went down towards the external ring and found that this was indeed tight without any hernias.,We then closed up the external oblique fascia and made an incision after doing a shave on the right and left scrotum into the upper scrotal sac with a curvilinear incision with a 15-blade knife. We then extended down to the subcutaneous tissue. Electrocautery was used for hemostasis. The hydrocele sac was visualized and then drained after incising into it with a curved Metzenbaum scissors. The testis was then delivered and found to have a moderate amount of scar tissue with a calcified appendix testis, which was then excised and sent to pathology. We then checked the upper aspect of the tunica vaginalis pouch and found that there was indeed no other connection, was up above, so we then wrapped the sac around the back of the testis, and closed it with a 4-0 chromic suture in a Lord maneuver. We then closed the upper aspect of the subdartos pouch with a pursestring suture of 4-0 chromic and placed the testis into the scrotum in the proper orientation. We then used an ilioinguinal nerve block and wound instillation on both incisional areas with 0.25% Marcaine without epinephrine; 15 mL was given.,We performed a similar procedure on the left, incising it at the scrotal area first, rather than below, and found this tunica vaginalis, and dissected it in a similar fashion and cauterized the appendix testis, which was not torsed. This was a smaller hydrocele, but because of the __________ shunt, we went up above and found that there was a very small connection, which was then dissected off the cord structures gently, twisted upon itself, suture ligated with a 2-0 Vicryl suture.,The ilioinguinal nerve block and other wound instillations again with 15 mL total of 0.25% Marcaine were then done by the surgeon as well. The external oblique fascia was closed on both sides with a running suture of 2-0 Vicryl. 4-0 chromic was then used to close the Scarpa fascia. The skin was closed with a 4-0 Rapide subcuticular closure. The scrotal incisions were closed with a subcutaneous and dartos closure using 4-0 chromic. IV Toradol was given at the end of the procedure. Dermabond tissue adhesive was placed on all 4 incisions. The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room." }

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

{ "text_length": 4332 }

{ "text": "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." }

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

{ "text_length": 2016 }

{ "text": "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." }

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

{ "text_length": 741 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1. Right thoracotomy, total decortication.,2. Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, 300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE: ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion. A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations. Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department. Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation. The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. Bronchoscope was then removed. Vital signs remained stable throughout this portion of the procedure. The patient was re-intubated by Anesthesia with a double lumen endotracheal tube. At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. At this point, the right chest was prepped and draped in the usual sterile fashion. The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine. The first port was placed through this incision intrathoracically. A bronchoscope was placed for inspection of the intrathoracic cavity. Pictures were taken. There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. At this point, a second port site anteriorly was placed under direct visualization. With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. Incision was made. The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. The chest cavity was entered with the right lung deflated per Anesthesia at our request. Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung. Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction. Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture. Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. Steri-Strips were applied along with sterile occlusive dressings. The patient was awakened from anesthesia without difficulty and extubated in the operating room. The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung. The patient was transported to the recovery with vital signs stable. Stat portable chest x-ray is pending. The patient will be admitted to the Intensive Care Unit for close monitoring overnight." }

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

{ "text_length": 4823 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. The patient was given sedation and monitored. Local anesthetic was used to insufflate the skin over sacral hiatus. A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood. A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level. After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected. The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected. Needle and catheter were removed intact. The patient was discharged in stable condition." }

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

{ "text_length": 1052 }

{ "text": "REASON FOR VISIT: , I have been asked to see this 63-year-old man with a dilated cardiomyopathy by Dr. X at ABCD Hospital. He presents with a chief complaint of heart failure.,HISTORY OF PRESENT ILLNESS: , In retrospect, he has had symptoms for the past year of heart failure. He feels in general \"OK,\" but is stressed and fatigued. He works hard running 3 companies. He has noted shortness of breath with exertion and occasional shortness of breath at rest. There has been some PND, but he sleeps on 1 pillow. He has no edema now, but has had some mild leg swelling in the past. There has never been any angina and he denies any palpitations, syncope or near syncope. When he takes his pulse, he notes some irregularity. He follows no special diet. He gets no regular exercise, although he has recently started walking for half an hour a day. Over the course of the past year, these symptoms have been slowly getting worse. He gained about 20 pounds over the past year.,There is no prior history of either heart failure or other heart problems.,His past medical history is remarkable for a right inguinal hernia repair done in 1982. He had trauma to his right thumb. There is no history of high blood pressure, diabetes mellitus or heart murmur.,On social history, he lives in San Salvador with his wife. He has a lot of stress in his life. He does not smoke, but does drink. He has high school education.,On family history, mother is alive at age 89. Father died at 72 of heart attack. He has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. He has 3 healthy girls and 9 healthy grandchildren.,A complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,MEDICATIONS: , Aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,ALLERGIES: , Denied.,MAJOR FINDINGS:, On my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. His blood pressure is 120/70 in each arm seated. His pulse is 80 beats per minute and regular. He is breathing 1two times per minute and that is unlabored. Eyelids are normal. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. Neck is supple and symmetrical without adenopathy or thyromegaly. Jugular venous pressure is normal. Carotids are brisk without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is regular. The first and second heart sounds are normal. He does have a fourth heart sound and a soft systolic murmur. The precordial impulse is enlarged. Abdomen is soft without hepatosplenomegaly or masses. He has no clubbing, cyanosis or peripheral edema. Distal pulses are normal throughout both arms and both legs. On neurologic examination, his mentation is normal. His mood and affect are normal. He is oriented to person, place, and time.,DATA: , His EKG shows sinus rhythm with left ventricular hypertrophy.,A metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. His peak oxygen consumption was 19.7 mL/kg/min, which is consistent with mild cardiopulmonary disease.,Laboratory data shows his TSH to be 1.33. His glucose is 97 and creatinine 0.9. Potassium is 4.3. He is not anemic. Urinalysis was normal.,I reviewed his echocardiogram personally. This shows a dilated cardiomyopathy with EF of 15%. The left ventricular diastolic dimension is 6.8 cm. There are no significant valvular abnormalities.,He had a stress thallium. His heart rate response to stress was appropriate. The thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. There is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. We got his post-stress EF to be 33% and the left ventricular cavity appeared to be enlarged. The total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,ASSESSMENTS: , This appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,PROBLEMS DIAGNOSES: ,1. Dilated cardiomyopathy.,2. Dyslipidemia.,PROCEDURES AND IMMUNIZATIONS: , None today.,PLANS: , I started him on an ACE inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. The dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. In addition, he could benefit from a loop diuretic such as furosemide. I did not start this as he is planning to go back home to San Salvador tomorrow. I will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,In terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. All of his siblings and his children should have an EKG and an echocardiogram to make sure they have not developed the same thing. There is a strong genetic component of this.,I will see him again in 3 to 6 months, whenever he can make it back here. He does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. If his LV function has not improved, he does have New York Heart Association Class II symptoms and so he would benefit from a prophylactic ICD.,Thank you for asking me to participate in his care.,MEDICATION CHANGES:, See the above." }

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

{ "text_length": 5870 }

{ "text": "ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation. She had an abnormal Pap smear in the 80s, which she failed to followup on until this year. Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion. She has elected definitive therapy with a total vaginal hysterectomy. She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear. Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia. There was an incidental cystotomy at the time of the creation of the bladder flap. This was repaired intraoperatively without difficulty. Postoperative, she did very well. Bowel and bladder function returned quickly. She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood. Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:, Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression. ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease." }

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

{ "text_length": 1843 }

{ "text": "DISCHARGE DIAGNOSES,1. Multiple extensive subcutaneous abscesses, right thigh.,2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,PROCEDURES PERFORMED,1. On 03/05/08, by Dr. X, was massive debridement of soft tissue, right lateral thigh and hip.,2. Soft tissue debridement on 03/16/08 of right thigh and hip by Dr. X.,3. Split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by Dr. Y.,REASON FOR ADMISSION: , The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction.,HOSPITAL COURSE: ,The patient was admitted on 03/05/08 by Dr. X. He was taken to the operating room. He underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. This led to a prolonged hospital course. The patient initially was treated with local wound care. He was treated with broad spectrum antibiotics. He ended up growing out different species of Clostridium. Infectious Disease consult was obtained from Dr. Z. He assisted in further antibiotic coverage throughout the rest of his hospitalization. The patient also had significant hypoalbuminemia, decreased nutrition. Given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. The patient had this superior area what appeared to be further necrotic, infected soft tissue. He went back to the OR on 03/16/08 and further resection done by Dr. X. After this, his wound appeared to be free of infection. He is treated with a wound VAC. He slowly, but progressively had significant progress in his wound. I went from a very poor-looking wound to a red granulated wound throughout its majority. He was thought ready for skin grafting. Note that the patient had serial ultrasounds given his high risk of DVT from this massive wound and need for decreased activity. These were negative. He was treated with SCDs to help decrease his risk. On 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. He underwent skin grafting to his right thigh and hip massive open wound. Donor sites were truncated. Postoperatively, the patient ended up with a vast majority of skin graft taking. To unable to take, he was kept on IV antibiotics, strict bed rest, and limited range of motion of his hip. He is continued on VAC dressing. Graft progressively improved with this therapy. Had another ultrasound, which was negative for DVT. The patient was mobilized up out of his bed. Infectious Disease recommendations were obtained. Plan was to complete additional 10 days of antibiotics at discharge. This will be oral antibiotics. I would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. So, decision was not made to excise this, but instead monitor. By 04/11/08, his graft looked good. It was pink and filling in. He looked stable for discharge. The patient was discharged to home.,DISCHARGE INSTRUCTIONS: , Discharge to home.,CONDITION: , Stable.,Antibiotic Augmentin XR script was written. He is okay to shower. Donor site and graft site dressing instruction orders were given for Home Health and the patient. His followup was arranged with Dr. X and myself." }

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

{ "text_length": 3743 }

{ "text": "REASON FOR VISIT: , Followup evaluation and management of chronic medical conditions.,HISTORY OF PRESENT ILLNESS:, The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite well as well. He has had no symptoms of hyperglycemia or hypoglycemia. He has had no falls. His right knee does pain him at times and he is using occasional doses of Tylenol for that. He wonders whether he could use a knee brace to help him with that issue as well. His spirits are good. He has had no incontinence. His memory is clear, as is his thinking.,MEDICATIONS:,1. Bumex - 2 mg daily.,2. Aspirin - 81 mg daily.,3. Lisinopril - 40 mg daily.,4. NPH insulin - 65 units in the morning and 25 units in the evening.,5. Zocor - 80 mg daily.,6. Toprol-XL - 200 mg daily.,7. Protonix - 40 mg daily.,8. Chondroitin/glucosamine - no longer using.,MAJOR FINDINGS:, Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%. He is afebrile. JVP is normal without HJR. CTAP. RRR. S1 and S2. Aortic murmur unchanged. Abdomen: Soft, NT without HSM, normal BS. Extremities: No edema on today's examination. Awake, alert, attentive, able to get up on to the examination table under his own power. Able to get up out of a chair with normal get up and go. Bilateral OA changes of the knee.,Creatinine 1.7, which was down from 2.3. A1c 7.6 down from 8.5. Total cholesterol 192, HDL 37, and triglycerides 487.,ASSESSMENTS:,1. Congestive heart failure, stable on current regimen. Continue.,2. Diabetes type II, A1c improved with increased doses of NPH insulin. Doing self-blood glucose monitoring with values in the morning between 100 and 130. Continue current regimen. Recheck A1c on return.,3. Hyperlipidemia, at last visit, he had 3+ protein in his urine. TSH was normal. We will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia. In the interim, both Dr. X and I have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia. Specifically we were considering TriCor (fenofibrate). Given his problems with high CPK values in the past for now, we have decided not to engage in that strategy. We will leave open for the future. Check fasting lipid panel today.,4. Chronic renal insufficiency, improved with reduction in dose of Bumex over time.,5. Arthritis, stable. I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day. He states he will inch that up slowly. With regard to a brace, he stated he used one in the past and that did not help very much. I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease. For now he will continue with his cane and walker.,6. Health maintenance, flu vaccination today.,PLANS: , Followup in 3 months, by phone sooner as needed." }

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

{ "text_length": 3145 }

{ "text": "PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma. ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST: Clear. There is no heart murmur.,ABDOMEN: Nontender.,PELVIC: There is a large mass in the vagina. ,HOSPITAL COURSE: , The patient went to surgery on the day of admission. The postoperative course was marked by fever and ileus. The patient regained bowel function. She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006: Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable., ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter. She will avoid lifting, driving, stairs, or intercourse. She will call me for fevers, drainage, bleeding, or pain. Family history, social history, and psychosocial needs per the social worker. The patient will follow up in my office in one week.,PATHOLOGY:, Mullerian adenosarcoma.,MEDICATIONS:, Percocet 5, #40, one q.3 h. p.r.n. pain." }

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

{ "text_length": 1086 }

{ "text": "SUBJECTIVE:, Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:, Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit. There is tenderness to palpation to the medial tubercle of the right foot. The pain is elicited along the medial arch as well. There are no open areas or signs of infection noted.,ASSESSMENT:, Plantar fascitis/heel spur syndrome, right foot.,PLAN:, The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate. He was given a low dye strapping and a heel lift was placed in his right shoe. The patient will be seen back in approximately one month for further evaluation if necessary. He was told to call if anything should occur before that. The patient was told to continue with the good work on his diabetic control." }

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

{ "text_length": 1424 }

{ "text": "CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician" }

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

{ "text_length": 4406 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1. Hiatal hernia.,2. Reflux esophagitis.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:, Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:, The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough. She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite. She was placed in the left lateral position and was given IV Demerol and Versed for sedation. When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated. At the GE junction, a hiatal hernia was present. There were mild inflammatory changes consistent with reflux esophagitis. The scope was then passed into the stomach. It was insufflated and the scope was coursed along the greater curvature to the antrum. The pylorus was patent. There was evidence of bile reflux in the antrum. The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation. The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized. The gastroscope was then slowly withdrawn. There were no other abnormalities noted in the fundus or body. Once again at the GE junction, esophageal biopsy was taken. The scope was then completely withdrawn. The patient tolerated the procedure and was transferred to the recovery room in stable condition. She will return to the General Medical Floor. We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions. She should also attempt significant weight loss." }

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

{ "text_length": 2059 }

{ "text": "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." }

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

{ "text_length": 6157 }

{ "text": "SUBJECTIVE:, This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,PHYSICAL EXAM: , Examination of her foot shows some well-healed surgical scars. On the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar. They are all old, and the surgery was done over a year ago. She is walking with a very slight limp. There is no redness. No heat. No swelling of the foot or the ankle. It is mildly tender around the medial side of the foot just inferior to the medial malleolus. It is not warm or red.,ASSESSMENT:, Foot pain.,PLAN:, She has been in here before. She seems very pleasant. Thought maybe she certainly might be having some significant pain, so I gave her some Lortab 7.5 to take with a refill. After she left, I got to thinking about it and looked into her record. She has been in here multiple times for pain medicine. She has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen Dr. XYZ not too long ago. We called Dr. XYZ office. Dr. XYZ nurse said that the patient did not have an appointment today. She has an appointment on June 15, 2004, for a postop check. They did not tell her they would not see her today because of insurance, so the patient was lying to me. We will keep that in mind the next time she returns, because she will likely be back. She did say that Project Access will be approving her insurance next week, so she will be able to see Dr. XYZ soon." }

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

{ "text_length": 2890 }

{ "text": "INDICATIONS:, Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:, Adenosine Myoview stress test.,STRESS ECG RESULTS:, The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes. The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute. Underlying atrial fibrillation noted, very wide QRS complexes. The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion." }

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

{ "text_length": 657 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1. Chronic adenotonsillitis.,2. Ankyloglossia,PROCEDURE PERFORMED:,1. Adenoidectomy and tonsillectomy.,2. Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:, Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION: ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion. A curved hemostat was used to grasp the lingual frenulum. The stat was removed and Metzenbaum scissors were used to free the lingual frenulum. Cautery was used to allow hemostasis. The patient was then turned. McIvor mouth gag was inserted. Tonsils and adenoids were exposed. The patient's right tonsil was first grasped with a curved hemostat. Needle tip cautery was used to free the superior pole of tonsil. The tonsil was then grasped in medial superior aspect with a straight hemostat. The tonsil fascia planes were identified with Bovie dissection along the plane. The tonsil was freed from anterior pillar and posterior pillar. Amputation occurred along the same plane as the patient's tongue. Suction cautery was then used to allow for hemostasis. The patient's adenoids were then viewed with an adenoid mirror. An adenoid curet was used to remove the patient's adenoid tissue. Specimen sent. Suction cautery was used to allow for hemostasis. Superior pole of left tonsil was then grasped with a curved hemostat. Superior pole was freed using needle tip Bovie dissection. Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars. The tonsil was then amputated at the same plane as tongue base. Hemostasis was achieved with using suction cautery. Mouth gag was removed. Dual position and occlusion were tested. The patient was extubated and tolerated the procedure well and sent back to PACU." }

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

{ "text_length": 2119 }

{ "text": "EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1. Left heart catheterization, coronary angiography, left ventriculography.,2. PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1. IV Valium.,2. IV Benadryl.,3. Subcutaneous lidocaine.,4. IV heparin.,5. IV ReoPro.,6. Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST: ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG. She was prepped and draped in the usual sterile fashion. The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained. The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed. The needle was exchanged for 6 French sheath. The wire was removed. The sheath was washed with sterile saline. Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed. A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD. The patient had an ACT check, received additional IV heparin and IV ReoPro. The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures. The balloon was deflated and angiography demonstrated establishment of flow. Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres. The balloon was deflated, reinflated at 12 atmospheres, deflated and removed. Final angiography demonstrated excellent clinical result. Additional angiography was performed with a wire out. Following this, the wire and the catheter was removed. Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views. This catheter was removed. The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve. At the end of procedure, wires and catheter were removed. Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site. There was no hematoma. Peripheral pulses _______ procedure. The patient tolerated the procedure well. Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1. Coronary angiography.,A. Left main free of obstruction.,B. LAD, subtotal proximal stenosis.,C. Circumflex large vessel with three large obtuse marginal branches. No high-grade obstruction, evidence of minimal plaquing.,D. Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2. Left ventriculogram. Left ventricular ejection fraction estimated at 45% to 50%. There was an akinetic apical wall.,3. Hemodynamics. Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1. Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2. Two-vessel coronary disease.,3. Mild-to-moderate impaired LV systolic function.,4. Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN: ,Overnight observation in ICU. Start aspirin, Plavix, beta-blocker and ACE inhibitor. Check serial cardiac enzymes. Further recommendations to follow. Check fasting lipid panel, in addition add a statin. Further recommendations to follow." }

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

{ "text_length": 3795 }

{ "text": "SUBJECTIVE: ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum. He says he does not feel short of breath. He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT: Denies any severe headache or sore throat.,CHEST: No true pain.,GI: No nausea, vomiting, or diarrhea.,PAST HISTORY:, He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation. He also lists some other medications. I do have his medications list. He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines. Those are the predominant medicines. He is not a diabetic. The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema. No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL: The patient appears comfortable. He did not appear to be in any respiratory distress. He was alert. I heard him cough once during the entire encounter. He did not bring up any sputum at that time.,VITAL SIGNS: His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT: Throat was normal.,RESPIRATORY: He was breathing normally. There was clear and equal breath sounds. He was speaking in full sentences. There was no accessory muscle use.,HEART: Sounded regular.,SKIN: Normal color, warm and dry.,NEUROLOGIC: Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week. The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen. The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding. The patient understands this. I then asked him if the cough was annoying him, he said it was. I offered him a cough syrup, which he agreed to take. The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup. I told to check in three days, if the symptoms were not getting better. The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later. His wife calls me very angry that I did not give him antibiotics. I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness." }

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

{ "text_length": 2964 }

{ "text": "CHIEF COMPLAINT:, Abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent. She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was \"normal.\" She was given oral antibiotics of Cipro and Flagyl. She has had no nausea and vomiting, but has had persistent associated anorexia. She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago. She denies any bright red blood per rectum and no history of recent melena. Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice. The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY: ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL: The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS: Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT: Head is grossly atraumatic and normocephalic. Sclerae are anicteric. The conjunctivae are non-injected.,NECK: Supple.,CHEST: Clear.,HEART: Regular rate and rhythm.,ABDOMEN: Generally nondistended and soft. She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness. There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC: Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES: Grossly and neurovascularly intact.,LABORATORY VALUES: ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal. Alkaline phosphatase elevated at 184. Liver function tests otherwise normal. Electrolytes normal. Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:, EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant. Currently is a nonacute abdomen. The working diagnosis would be sigmoid diverticulitis. She does have a history in the distant past of sigmoid diverticulitis. I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth. The patient was seen 5 years ago by Dr. Y in Colorectal Surgery. We will consult her also for evaluation. The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically. The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup." }

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

{ "text_length": 3504 }

{ "text": "CC:, Found unresponsive.,HX: , 39 y/o RHF complained of a severe HA at 2AM 11/4/92. It was unclear whether she had been having HA prior to this. She took an unknown analgesic, then vomited, then lay down in bed with her husband. When her husband awoke at 8AM he found her unresponsive with \"stiff straight arms\" and a \"strange breathing pattern.\" A Brain CT scan revealed a large intracranial mass. She was intubated and hyperventilated to ABG (7.43/36/398). Other local lab values included: WBC 9.8, RBC 3.74, Hgb 13.8, Hct 40.7, Cr 0.5, BUN 8.5, Glucose 187, Na 140, K 4.0, Cl 107. She was given Mannitol 1gm/kg IV load, DPH 20mg/kg IV load, and transferred by helicopter to UIHC.,PMH:, 1)Myasthenia Gravis for 15 years, s/p Thymectomy,MEDS:, Imuran, Prednisone, Mestinon, Mannitol, DPH, IV NS,FHX/SHX:, Married. Tobacco 10 pack-year; quit nearly 10 years ago. ETOH/Substance Abuse unknown.,EXAM:, 35.8F, 99BPM, BP117/72, Mechanically ventilated at a rate of 22RPM on !00%FiO2. Unresponsive to verbal stimulation. CN: Pupils 7mm/5mm and unresponsive to light (fixed). No spontaneous eye movement or blink to threat. No papilledema or intraocular hemorrhage noted. Trace corneal reflexes bilaterally. No gag reflex. No oculocephalic reflex. MOTOR/SENSORY: No spontaneous movement. On noxious stimulation (Deep nail bed pressure) she either extended both upper extremities (RUE>LUE), or withdrew the stimulated extremity (right > left). Gait/Station/Coordination no tested. Reflexes: 1+ on right and 2+ on left with bilateral Babinski signs.,HCT 11/4/92: Large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . There is low parenchymal density within the white matter. A hyperdense ring lies peripherally and may represent hemorrhage or calcification. The mass demonstrates inhomogeneous enhancement with contrast.,COURSE:, Head of bed elevated to 30 degrees, Mannitol and DPH were continued. MRI of Brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. She underwent surgical resection of the tumor. Pathological analysis was consistent with adenocarcinoma. GYN exam, CT Abdomen and Pelvis, Bone scan were unremarkable. CXR revealed an right upper lobe lung nodule. She did not undergo thoracic biopsy due to poor condition. She received 3000 cGy cranial XRT in ten fractions and following this was discharged to a rehabilitation center.,In March, 1993 the patient exhibited right ptosis, poor adduction and abduction OD, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. She was ambulatory with an ataxic gait.,She was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and T8 sensory level. MRI brainstem/spine on that day revealed decreased T1 signal in the C2, C3, C6 vertebral bodies, increased T2 signal in the anterior medulla, and tectum, and spinal cord (C7-T3). Following injection of Gadolinium there was diffuse leptomeningeal enhancement from C7-T7 These findings were felt consistent with metastatic disease including possible leptomeningeal spread. Neurosurgery and Radiation Oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. The patient was treated with Decadron and analgesics and discharged to a hospice center (her choice). She died a few months later." }

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

{ "text_length": 3432 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old man with the AIDS complicated with recent cryptococcal infection, disseminated MAC and Kaposi's sarcoma. His viral load in July of 2007 was 254,000 and CD4 count was 7. He was recently admitted for debility and possible pneumonia. He was started on antiretroviral therapy, as well as Cipro and Flagyl and was also found to have pleural effusion on the right. His history is also significant for pancreatitis and transient renal failure during last hospitalization. He became frustrated since he was not getting better and discontinued all antibiotics. When taken home yesterday, he had symptoms consistent with a partial bowel obstruction. He was vomiting and had no bowel movements for a few days. Last night, was able to have a bowel movement and has not vomited since then. He was able to take small amounts of food. He now has persistent cough productive of clear sputum and some shortness of breath. He also complains of pain at his KS lesions on the right leg and left thigh, especially when touched, although that pain is incidental and not present when he is simply lying down. He has overall weakness.,PAST MEDICAL HISTORY: , Unremarkable.,MEDICATIONS: , Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped. His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.,ALLERGIES:, He has no known allergies.,SOCIAL HISTORY: , The patient is now staying with his mother. He is the youngest of six children. Code Status: DNR. His brother is the health care proxy.,PHYSICAL EXAMINATION:, Blood pressure 140/80, pulse 120, and respirations 28. Temperature 103.9. General Appearance: Ill-looking young man, diaphoretic. PERRLA, 3 mm. Oral mucosa moist without lesions. Lungs: Diminished breath sounds in the right middle lower lobe. Heart: RRR without murmurs. Abdomen: Distended with soft and nontender. Diminished bowel sounds. Extremities: Without cyanosis or edema. There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender. Neurological Exam: Cranial nerves II through XII are grossly intact. There is normal tone. Power is 4/5. DTRs nonreactive. Normal fine touch. Mental Status: The patient is somnolent, but arousable. Withdrawn affect. Normal speech and though process.,ASSESSMENT AND PLAN:,1. AIDS complicated with multiple opportunistic infections with poor performance status, which suggested a limited prognosis of less than six months. He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments.,2. Pain, which is somatic nociceptive from KS lesions. The patient has not tolerated morphine in the past. We will start oxycodone 5 mg q.2h. as needed.,3. Cough. We will use oxycodone with the same indication as well.,4. Fever. We encouraged him to use Tylenol as needed.,5. Insomnia. We will use lorazepam 0.25-0.5 mg at bedtime as needed.,6. Psychosocial. We discussed his coping with the diagnosis. He is fully aware of his limited prognosis. Supportive counseling was provided to his mother.,Length of the encounter was one hour; more than half spent on exchange of information.," }

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

{ "text_length": 3303 }

{ "text": "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:" }

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

{ "text_length": 1690 }

{ "text": "EXAM: , CT of abdomen with and without contrast. CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI. There is re-demonstration of multiple bilateral cystic renal lesions. Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts. There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration. This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole. No other enhancing renal masses were seen. The visualized liver, spleen, pancreas, and adrenal glands were unremarkable. There are changes of cholecystectomy. Mild prominence of the common bile duct is likely secondary to cholecystectomy. There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear. No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described. Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion. The patient was placed in the decubitus position. The region overlying the left renal mass of note was marked. Area was prepped and draped in usual sterile fashion. Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate. The Versed and fentanyl were given to achieve conscious sedation. Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis. Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia. No perinephric fluid/hematoma was identified. The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described." }

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

{ "text_length": 2194 }

{ "text": "PREOPERATIVE DIAGNOSIS: ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:, Esophageal rupture.,OPERATION PERFORMED,1. Left thoracotomy with drainage of pleural fluid collection.,2. Esophageal exploration and repair of esophageal perforation.,3. Diagnostic laparoscopy and gastrostomy.,4. Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching. He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room. He was placed in a supine position on the operating table. After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll. Left chest was prepped and draped in a usual sterile fashion. After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace. The left lung was deflated and the pleural cavity entered. The Finochietto retractor was used to help provide exposure. The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid. Cultures of this were sampled and sent for microbiology analysis. The left pleural space was then copiously irrigated. A careful expiration demonstrated that the rupture appeared to be sealed. There was crepitus within the mediastinal cavity. The mediastinum was opened and explored and the esophagus was explored. The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus. It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area. The area was copiously irrigated, this provided nice coverage and repair. After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French. These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures. Muscle layers were closed with running #1 Vicryl sutures. The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position. A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed. A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced. The laparoscope was introduced. A single additional left-sided separator trocar was introduced. It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance. The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely. The skin incision was made and the gastric lumen was then accessed with the Seldinger technique. Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire. #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated. We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall. The T-fasteners were all crimped and secured into position. As was in the plan, the gastrostomy was secured to the skin and into the tube. Sterile dressing was applied. Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation. Radiographic gastrostomy tube study with gastric contrast, with" }

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

{ "text_length": 4311 }

{ "text": "EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration. There are no comparison studies.,FINDINGS: ,There are no abnormal extraaxial fluid collections. There is no midline shift or mass effect. Ventricular system demonstrates no dilatation. There is no evidence of acute intracranial hemorrhage. The calvarium is intact. There is a laceration in the left parietal region of the scalp without underlying calvarial fractures. The mastoid air cells are clear.,IMPRESSION: ,No acute intracranial process." }

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

{ "text_length": 660 }

{ "text": "CHIEF COMPLAINT:, Right hydronephrosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative.,PAST MEDICAL HISTORY: , Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,PAST SURGICAL HISTORY: , Lumpectomy, hysterectomy.,MEDICATIONS:, Diovan HCT 80/12.5 mg daily, metformin 500 mg daily.,ALLERGIES:, None.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:, She is retired. Does not smoke or drink.,REVIEW OF SYSTEMS:, I have reviewed his review of systems sheet and it is on the chart.,PHYSICAL EXAMINATION:, Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness.,IMPRESSION AND PLAN: , Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests." }

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

{ "text_length": 2195 }

{ "text": "OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch." }

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

{ "text_length": 1592 }

{ "text": "HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations. Symptoms occur three to four times per year and follow no identifiable pattern. She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so. Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate. The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision. On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines. While working on a computer, she had a spell. Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital. She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse. She does have a couple of sodas and at least one to two coffees daily. She is a nonsmoker. She is a mother of two. There is no family history of congenital heart disease. She has had no history of thoracic trauma. No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia. Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted. Pupils are reactive. Sclerae nonicteric. Mucous membranes are moist. Neck veins not distended. No bruits. Lungs are clear. Cardiac exam is regular without murmurs, gallops, or rubs. Abdomen is soft without guarding, rebound masses, or bruits. Extremities well perfused. No edema. Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals. No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable. No evidence of myocardial injury. Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period. Outpatient workup would be appropriate. Event recorder should be obtained and the patient can be seen again in the office upon completion of that study. Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy. The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation. We will be happy to follow her both during this hospitalization and following discharge. Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5. CT scan showed no evidence of pulmonary embolus. Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations. In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.," }

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

{ "text_length": 3569 }

{ "text": "Doctor's Address,Dear Doctor:,This letter serves as a reintroduction of my patient, A, who will be seeing you on Thursday, 06/12/2008. As you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities. His current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg. He has been through Wound Clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this. He has been seen by Dr. X for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain. He was seen by Dr. Y at Orthopedic Associates for review of this. However, in my discussion with Dr. Z and his evaluation of Mr. A, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his RST, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his RST symptoms on his left leg if he would have an amputation. Based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, Dr. Z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds. As you may or may not know we have certainly pursued aggressive significant measures to try to improve Mr. A's pain. He has been to Cleveland Clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain. He currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and Dilaudid two tablets by mouth every two hours to help reduce his pain. He also is currently taking Neurontin 1600 mg three times a day, Effexor XR 250 mg once a day, Cytomel 25 mcg once a day, Seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, Prinivil 20 mg p.o. q. day, and Mevacor 40 mg p.o. q day.,I appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation. Dr. Z and I have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion. He has been evaluated by Dr. X for rehab concerns to determine. He agrees that a less aggressive form of therapy may be most appropriate.,I thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation. If you have any questions regarding his care please feel free to call me at my office. Otherwise, I look forward to hearing back from you shortly after your evaluation. Please feel free to call me if it is possible or if you have any questions about anything." }

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

{ "text_length": 2839 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Dysmenorrhea.,3. Dyspareunia.,4. Endometriosis.,5. Enlarged uterus.,6. Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1. Chronic pelvic pain.,2. Dysmenorrhea.,3. Dyspareunia.,4. Endometriosis.,5. Enlarged uterus.,6. Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:, General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube. All endometriosis had been identified laparoscopically from a previous surgery. At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department. The patient was then prepped and draped in the usual fashion for a low transverse incision. Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision. This was extended down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion. The edges of the fascia were grasped with Kocher. Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique. The abdominal rectus muscle was divided in the midline and extended in a vertical fashion. Perineum was entered at the high point and extended in a vertical fashion as well. An O'Connor-O'Sullivan retractor was put in place on either side. A bladder blade was put in place as well. Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade. The bladder flap was released with Metzenbaum scissors and then dissected away caudally. EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip. Two Heaney were placed on either side of the uterus at the level of cardinal ligaments. These were sharply incised and both pedicles were tied off with 1 Vicryl suture. Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault. A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact. From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches. Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first. Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath. The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips. The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity. Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack. Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle. The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center. The subcutaneous tissue was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples. Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood. The patient was taken to recovery room in stable condition. Instrument count, needle count, and sponge counts were all correct." }

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

{ "text_length": 4387 }

{ "text": "PREOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2. Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied." }

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

{ "text_length": 2061 }

{ "text": "CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning. He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it. Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful. He had no voiding or stooling problems. No nausea, vomiting or fever. Family denies trauma or dysuria. At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved. He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning. He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation. He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago. He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:, The patient has no known allergies. He is term delivery via spontaneous vaginal delivery. He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:, All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking. He is not in school.,MEDICATIONS:, He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS: On physical exam, weight is 15.9 kg.,GENERAL: The patient is a cooperative little boy.,HEENT: Normal head and neck exam. No oral or nasal discharge.,NECK: Without masses.,CHEST: Without masses.,LUNGS: Clear.,CARDIAC: Without murmurs or gallops.,ABDOMEN: Soft. No masses or tenderness. His scrotum did not have any swelling at the present time. There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted. No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only. His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES: He had full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left. This is personally reviewed by me. The right was normal. No masses were appreciated. There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem. If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found. I discussed the pre and postsurgical care with the parents. Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure. The parents understand and wished to proceed. We will schedule this later today emergently." }

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

{ "text_length": 3882 }

{ "text": "ADMISSION DIAGNOSIS: ,Adenocarcinoma of the prostate.,HISTORY:, The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5). The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base. The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion. He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:, Atrial fibrillation.,MEDICATIONS:, Coumadin and lisinopril.,SOCIAL HISTORY: ,Smokes none. Alcohol none.,ALLERGIES:, NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills. Eyes: No change in vision or diplopia. Ears: No tinnitus or vertigo. Mouth: No dysphagia. Pulmonary: No chronic cough or shortness of breath. Cardiac: No angina or palpitations. GI: No nausea, vomiting, diarrhea or constipation. Musculoskeletal: No arthritides or myalgias. Hematopoietic: No easy bleeding or bruising. Skin: No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL: The patient is well developed and well nourished.,HEENT: Head is normocephalic. Eyes, pupils are equal. Conjunctivae are pink. Sclerae are anicteric.,NECK: There is no adenopathy.,PULMONARY: Respirations are unlabored.,HEART: Regular rhythm.,ABDOMEN: Liver, spleen, kidney, and bladder are not palpable. There are no discernible masses. There are no peritoneal signs.,GENITALIA: The penis has no plaques. Meatus is on the glans. Scrotal skin is healthy. Testicles are fair consistency. Epididymides are nontender.,RECTAL: The prostate is +1 to 2/4. There are no areas that are suspicious for tumor. Consistency is even. Sidewalls are sharp. Seminal vesicles are not palpable.,MUSCULOSKELETAL: The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC: There are no gross focal neurologic abnormalities.,IMPRESSION:,1. Adenocarcinoma of the prostate.,2. Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery. He has _________ surviving prostate cancer by Dr. Y. He is aware of incontinency, both total and partial. We discussed erectile dysfunction. We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death. He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely. He had no questions at the conclusion of our last conversation." }

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

{ "text_length": 2877 }

{ "text": "ADMISSION DIAGNOSIS:, Morbid obesity. BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity. BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years. She has made multiple attempts at nonsurgical weight loss without success. She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate. She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure. She tolerated without difficulty. She was admitted to the floor post procedure. Her postoperative course has been unremarkable. On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty. She has ambulated and had no complaints. Today, on postoperative day 2, the patient continues to do well. Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet. At this point, it is felt that she is stable for discharge. Her drain was discontinued.,DISCHARGE INSTRUCTIONS:, Liquid diet x1 week, then advance to pureed and soft as tolerated. No heavy lifting, greater than 10 pounds x4 weeks. The patient is instructed to not engage in any strenuous activity, but maintain mobility. No driving for 1 to 2 weeks. She must be able to stop in an emergency and be off narcotic pain medicine. She may shower. She needs to keep her wounds clean and dry. She needs to follow up in my office in 1 week for postoperative evaluation. She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain. She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:, She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace." }

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

{ "text_length": 2054 }

{ "text": "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." }

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

{ "text_length": 4127 }

{ "text": "ADMITTING DIAGNOSIS: , Kawasaki disease.,DISCHARGE DIAGNOSIS:, Kawasaki disease, resolving.,HOSPITAL COURSE:, This is a 14-month-old baby boy Caucasian who came in with presumptive diagnosis of Kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated CRP and ESR. When he was sent to the hospital, he had a fever of 102. Subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and IVIG. Echocardiogram was also done, which was negative. IVIG was done x1, and between 12 hours of IVIG, he spiked fever again; it was repeated twice, and then after second IVIG, he did not spike any more fever. Today, his fever and his rash have completely resolved. He does not have any conjunctivitis and no redness of mucous membranes. He is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,DISCHARGE ACTIVITIES:, Ad-lib.,DISCHARGE DIET: , PO ad-lib.,DISCHARGE MEDICATIONS: , Aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then Prevacid also to prevent his GI from aspirin 15 mg p.o. once a day. He will be followed by his primary doctor in 2 to 3 days. Cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of IVIG, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible." }

[ { "label": " Allergy / Immunology", "score": 1 } ]

{ "text_length": 1566 }

{ "text": "SUBJECTIVE:, This 3-year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:, He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs: Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.,Neck: Supple without adenopathy.,Lungs: Clear.,Cardiac: Regular rate and rhythm without murmurs.,Abdomen: Soft without organomegaly, masses, or tenderness.,ASSESSMENT:, Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.,PLAN:, I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation." }

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

{ "text_length": 1809 }

{ "text": "The patient states that she has been doing fairly well at home. She balances her own checkbook. She does not do her own taxes, but she has never done so in the past. She states that she has no problems with cooking meals, getting her own meals, and she is still currently driving. She denies burning any dishes because she forgot them on the stove or forgetting what she is doing in the middle of a task or getting lost while she is driving around or getting lost in her own home. She states that she is very good remembering the names of her family members and does not forget important birthdays such as the date of birth of her grandchildren. She is unfortunately living alone, and although she seems to miss her grandchildren and is estranged from her son, she denies any symptoms of frank depression. There is unfortunately no one available to us to corroborate how well she is doing at home. She lives alone and takes care of herself and does not communicate very much with her brother and sister. She also does not communicate very much with her son who lives in Santa Cruz or her grandchildren. She denied any sort of personality change, paranoid ideas or hallucinations. She does appear to have headaches that can be severe about four times a month and have primarily photophobia and some nausea and occasionally emesis associated with it. When these headaches are very severe, she goes to the emergency room to get a single shot. She is unclear if this is some sort of a migraine medication or just a primary pain medication. She takes Fiorinal for these headaches and she states that this helps greatly. She denies visual or migraine symptoms.,REVIEW OF SYSTEMS: , Negative for any sort of focal neurologic deficits such as weakness, numbness, visual changes, dysarthria, diplopia or dysphagia. She also denies any sort of movement disorders, tremors, rigidities or clonus. Her personal opinion is that some of her memory problems may be due to simply to her age and/or nervousness. She is unclear as if her memory is any worse than anyone else in her age group.,PAST MEDICAL HISTORY: , Significant for mesothelioma, which was diagnosed seemingly more than 20 to 25 years ago. The patient was not sure of exactly when it was diagnosed. This has been treated surgically by debulking operations for which she states that she has undergone about 10 operations. The mesothelioma is in her abdomen. She does not know of any history of having lung mesothelioma. She states that she has never gotten chemotherapy or radiation for her mesothelioma. Furthermore, she states that her last surgical debulking was more than 10 years ago and her disease has been fairly stable. She does have a history of three car accidents that she says were all rear-enders where she was hit while essentially in a stopped position. These have all occurred over the past five years. She also has a diagnosis of dementing illness, possibly Alzheimer disease from her previous neurology consultation. This diagnosis was given in March 2006.,MEDICATIONS:, Fiorinal, p.r.n. aspirin, unclear if baby or full sized, Premarin unclear of the dose.,ALLERGIES:, NONE.,SOCIAL HISTORY:, Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren.,FAMILY HISTORY: , Significant for lung, liver, and prostate cancer. Her mother died in her 80s of \"old age,\" but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.,PHYSICAL EXAMINATION: , Her blood pressure is 152/92, pulse 80, and weight 80.7 kg. She is alert and well nourished in no apparent distress. She occasionally fumbles with questions of orientation, missing the day and the date. She also did not know the name of the hospital, she thought it was O'Connor and she thought she was in Orange County and also did not know the floor of the hospital that we are in. She lost three points for recall. Even with prompting, she could not remember the objects that she was given to remember. Her Mini Mental Score was 22/30. There were no naming problems or problems with repetition. There were also no signs of dysarthria. Her pupils were bilaterally reactive to light and accommodation. Her extraocular movements were intact. Her visual fields were full to confrontation. Her sensations of her face, arm, and leg were normal. There were no signs of neglect with double simultaneous stimulation. Tongue was midline. Her palate was symmetric. Her face was symmetric as well. Strength was approximately 5/5. She did have some right knee pain and she had a mildly antalgic gait due to her right knee pain. Her reflexes were symmetric and +2 except for her toes, which were +1 to trace. Her plantar reflexes were mute. Her sensation was normal for pain, temperature, and vibration. There were no signs of ataxia on finger-to-nose and there was no dysdiadochokinesia. Gait was narrow and she could toe walk briefly and heel walk without difficulty.,SUMMARY:, Ms. A is a pleasant 72-year-old right-handed woman with a history of mesothelioma that appears stable at this time and likely mild dementia, most likely Alzheimer type. We tactfully discussed the patient's diagnosis with her, and she felt reassured. We told her that this most likely was in the earlier stages of disease and she would benefit from trying Aricept. She stated that she did not have the prescription anymore from her outpatient neurology consult for the Aricept, so we wrote her another prescription for Aricept. The patient herself seemed very concerned about the stigma of the disease, but our lengthy discussion, expressed genuine understanding as to why her outpatient physician had reported her to DMV. It was explicitly told to not drive by her outpatient neurologist and we concur with this assessment. She will follow up with us in the next six months and will call us if she has any problems with the Aricept. She was written for Aricept to start at 5 mg for three weeks, and if she has no side effects which typically are GI side effects, then she can go up to 10 mg a day. We also reviewed with Ms. A the findings for outpatient MRI, which showed some mild atrophy per report and also that her metabolic workup, which included an RPR, TSH, and B12 were all within normal limits.," }

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

{ "text_length": 7253 }

{ "text": "The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilation, but 80% effacement by nurse examination. The patient was admitted. Expected management was utilized initially. Stadol was used for analgesia. Examination did not reveal vulvar lesions. Epidural was administered. Membranes ruptured spontaneously. Cervical dilation progressed. Acceleration-deceleration complexes were seen. Overall, fetal heart tones remained reassuring during the progress of labor. The patient was allowed to \"labor down\" during second stage. Early decelerations were seen as well as acceleration-deceleration complexes. Overall, fetal heart tones were reassuring. Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. There was no loop or coil of cord. Infant was vigorous female sex. Oropharynx was aggressively aspirated. Cord blood was obtained. Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue. Examination of the cervix did not reveal lacerations. Upper vaginal lacerations were not seen. Multiple first-degree lacerations were present. Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried. Post-approximation examination of the rectum showed smooth, intact mucosa. Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders. Nursing personnel will be notified of Gilbert's syndrome." }

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

{ "text_length": 2144 }

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

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

{ "text_length": 1606 }

{ "text": "PROCEDURE:, Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:, Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:, None.,PROCEDURE:, The area around the lesion was anesthetized after she gave consent for her procedure. Punch biopsy including some portion of lesion and normal tissue was performed. Hemostasis was completed with pressure holding. The biopsy site was approximated with non-dissolvable suture. The area was hemostatic. All counts were correct and there were no complications. The patient tolerated the procedure well. She will see us back in approximately five days.," }

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

{ "text_length": 603 }

{ "text": "FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician." }

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

{ "text_length": 631 }

{ "text": "REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:, Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY: ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity. The right ulnar sensory amplitude was reduced with slowing of the conduction velocity. The right radial sensory amplitude was reduced with slowing of the conduction velocity. The right sural and left sural sensory responses were absent. The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing. The distal amplitude was very reduced, and there was a reduction with proximal stimulation. The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow. The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee. The right tibial motor response showed a reduced amplitude with prolongation of the distal latency. The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing. The left tibial motor response showed a decreased amplitude with a borderline normal distal latency. The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above. With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles. Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue. There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue. In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study. There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments. There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities. There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow. Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease. However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease. The patient will return for further evaluation." }

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

{ "text_length": 3029 }

{ "text": "DIAGNOSIS: , Left sciatica.,ANESTHESIA: , Intravenous sedation,NAME OF OPERATION:,1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy.,2. Left L4-5 transforaminal epidural steroid block with fluoroscopy.,3. Monitored intravenous Versed sedation.,PROCEDURE: , The patient was taken to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the \"neck of the scotty dog\" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.,I then went up to the L4-5 level, and using a similar technique, injected the patient transforaminally at the L4-5 level. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected at the L4-5 level just as at the L5-S1 level. The patient had pain down his left leg during the injection, primarily at the L5-S1 level similar to what he normally experiences. He was awake and alert, and taken to the recovery room in good condition. His left leg pain was relieved." }

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

{ "text_length": 1786 }

{ "text": "PREOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1. Request for cosmetic surgery.,2. Facial asymmetry following motor vehicle accident.,PROCEDURES:,1. Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2. Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago. Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions. She had requested a procedure to bring about further facial asymmetry. She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate. She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left. Preoperative workup including CT scan failed to show any skeletal trauma. The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:, The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake. General endotracheal anesthesia was induced with a #6 endotracheal tube. All appropriate measures were taken to preserve the vocal cords in a professional singer. Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia. The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine. Adequate time for vasoconstriction and anesthesia was allowed to be obtained. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture was placed in the right lower lid. For traction, it was brought anteriorly. The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe. A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone. The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present. The inferior oblique muscle was identified, preserved, and protected throughout the procedure. The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut. Contralateral side was treated in similar fashion with like results and throughout the procedure. Lacri-Lube was in the eyes in order to maintain hydration. Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds. Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia. A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane. Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle. The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle. It was bipolar electrocauteried and the tunnel was further dissected free and opened. The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection. The guard was removed and the suspension spikes were engaged into the soft tissues. The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally. The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture. Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained. The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples. The sterile dressing was applied. The patient was awakened in the operating room and taken to the recovery room in good condition." }

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

{ "text_length": 5154 }

{ "text": "CHIEF COMPLAINT:, Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work. She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle. She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.,FAMILY HISTORY:, Noncontributory.,REVIEW OF SYSTEMS:,Pulm: No cough, No wheezing, No shortness of breath,CV: No chest pain or palpitations,GI: No abdominal pain. No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE: No acute distress,VITAL SIGNS: Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK: Supple. No lymphadenopathy. No thyromegaly.,CHEST: Clear to auscultation bilaterally.,HEART: Regular rate and rhythm. No murmurs.,ABDOMEN: Non-distended, nontender, normal active bowel sounds.,EXTREMITIES: No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL: The spine is straight and there is no significant muscle spasm or tenderness there. Both knees appear to be non-traumatic with no deformity or significant tenderness. The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender. There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation. Radiologic interpretation is pending., ,IMPRESSION:, Right ankle sprain.,PLAN:,1. Motrin 800 mg t.i.d.,2. Tylenol 1 gm q.i.d. as needed.,3. Walking cast is prescribed.,4. I told the patient to call back if any problems. The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q. 8 hours p.r.n. pain #60 with no refills." }

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

{ "text_length": 2204 }

{ "text": "PAST MEDICAL HISTORY:, He has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, and lifting objects off the floor. He exercises three times a week at home and does cardio. He has difficulty walking two blocks or five flights of stairs. Difficulty with snoring. He has muscle and joint pains including knee pain, back pain, foot and ankle pain, and swelling. He has gastroesophageal reflux disease.,PAST SURGICAL HISTORY:, Includes reconstructive surgery on his right hand 13 years ago. ,SOCIAL HISTORY:, He is currently single. He has about ten drinks a year. He had smoked significantly up until several months ago. He now smokes less than three cigarettes a day.,FAMILY HISTORY:, Heart disease in both grandfathers, grandmother with stroke, and a grandmother with diabetes. Denies obesity and hypertension in other family members.,CURRENT MEDICATIONS:, None.,ALLERGIES:, He is allergic to Penicillin.,MISCELLANEOUS/EATING HISTORY:, He has been going to support groups for seven months with Lynn Holmberg in Greenwich and he is from Eastchester, New York and he feels that we are the appropriate program. He had a poor experience with the Greenwich program. Eating history, he is not an emotional eater. Does not like sweets. He likes big portions and carbohydrates. He likes chicken and not steak. He currently weighs 312 pounds. Ideal body weight would be 170 pounds. He is 142 pounds overweight. If ,he lost 60% of his excess body weight that would be 84 pounds and he should weigh about 228.,REVIEW OF SYSTEMS: ,Negative for head, neck, heart, lungs, GI, GU, orthopedic, and skin. Specifically denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, high cholesterol, pulmonary embolism, high blood pressure, CVA, venous insufficiency, thrombophlebitis, asthma, shortness of breath, COPD, emphysema, sleep apnea, diabetes, leg and foot swelling, osteoarthritis, rheumatoid arthritis, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, hemorrhoids, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. Denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,PHYSICAL EXAMINATION:, He is alert and oriented x 3. Cranial nerves II-XII are intact. Afebrile. Vital Signs are stable." }

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

{ "text_length": 2431 }

{ "text": "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." }

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

{ "text_length": 1037 }

{ "text": "PROCEDURE:, Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis. The foreskin was normal in appearance and measured 1.6 cm. There was no bleeding at the circumcision site.,PROCEDURE:, Patient was placed on the circumcision restraint board. EMLA had been applied approximately 90 minutes before. A time-out was completed satisfactorily per protocol. The area was prepped with Betadine. The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection. A Mogen clamp was applied to the cervix. The excess foreskin was excised with the scalpel. The clamp was removed. At this point, the procedure was terminated. Sterile Vaseline and gauze was applied to the glans penis. There were no complications. There was minimal blood loss." }

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

{ "text_length": 810 }

{ "text": "EXAM: ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections. There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies. A mild amount of anterior osteophytic lipping is seen involving the thoracic spine. There is a suggestion of generalized osteoporosis. The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis." }

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

{ "text_length": 678 }

{ "text": "ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:, Ms. ABC is a 57-year-old woman. She suffers from morbid obesity. She also has diabetes and obstructive sleep apnea. She was evaluated in the Bariatric Surgical Center for placement of a band. During her workup, she was noted to have evidence of cholelithiasis. It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band. The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438. She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS: ,To return to the Medifast diet. To continue with her blood glucose. She needs to follow up with Dr. B, and she will see me next week on Friday. We will determine if we will proceed with her lap band at that time. She may shower. She needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars." }

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

{ "text_length": 2290 }

{ "text": "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." }

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

{ "text_length": 1250 }

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

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

{ "text_length": 3853 }

{ "text": "CHIEF COMPLAINT: ,Blood in toilet.,HISTORY: , Ms. ABC is a 77-year-old female who is brought down by way of ambulance from XYZ Nursing Home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet. They did not note any urine or stool in the toilet and the patient had no acute complaints. The patient is unfortunately a poor historian in that she has dementia and does not recall any of the events. The patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and GI complaints. There is no other history provided by the nursing staff from XYZ. There apparently were no clots noted within there. She does not have a history of being on anticoagulants.,PAST MEDICAL HISTORY: , Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.,PAST SURGICAL HISTORY: ,Unknown.,SOCIAL HISTORY: , No tobacco or alcohol.,MEDICATIONS: , Listed in the medical records.,ALLERGIES:, No known drug allergies.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable.,GENERAL: This is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,HEENT: Visually normal. Pupils are reactive. TMs, canals, nasal mucosa, and oropharynx are intact.,NECK: No lymphadenopathy or JVD.,HEART: Regular rate and rhythm. S1, S2. No murmurs, gallops, or rubs.,LUNGS: Clear to auscultation. No wheeze, rales, or rhonchi.,ABDOMEN: Benign, flat, soft, nontender, and nondistended. Bowel sounds active. No organomegaly or mass noted.,GU/RECTAL: External rectum was normal. No obvious blood internally. There is no stool noted within the vault. There is no gross amount of blood noted within the vault. Guaiac was done and was trace positive. Visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,EXTREMITIES: No significant abnormalities.,WORKUP: , CT abdomen and pelvis was negative. CBC was entirely within normal limits without any signs of anemia with an H and H of 14 and 42%. CMP also within normal limits. PTT, PT, and INR were normal. Attempts at getting the patient to give A urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of Foley catheterization.,ER COURSE:, Uneventful. I have discussed the patient in full with Dr. X who agrees that she does not require any further workup or evaluation as an inpatient. We have decided to send the patient back to XYZ with observation by the staff there. She will have a CBC done daily for the next 3 days with results to Dr. X. They are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at XYZ for blood.,ASSESSMENT: , Questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed." }

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

{ "text_length": 3014 }

{ "text": "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." }

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

{ "text_length": 3058 }

{ "text": "OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position. After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed. The patient was placed in the right lateral decubitus position. The left chest and back were prepped and draped in a sterile fashion. A right lateral thoracotomy incision was made. Subcutaneous flaps were raised. The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly. The posterior border of the pectoralis was freed up and it was retracted anteriorly. The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery. The major fissure was then taken down and arteries identified. The artery was dissected free and it was divided with an Endo GIA stapler. The vein was then dissected free and divided with an Endo GIA stapler. The bronchus was then cleaned of all nodal tissue. A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor. Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen. Hemostasis noted. Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl. A subcutaneous drain was placed. Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch." }

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

{ "text_length": 1592 }

{ "text": "REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen. No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas. No pancreatic ductal dilatation is seen. There is no abnormal adjacent stranding. No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber. There is no evidence for obstruction. The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable. There is a 4.2 cm cystic lesion of the right adnexal region. No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1. A 2.2 cm low attenuation lesion is seen at the pancreatic tail. This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised. Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed. Alternatively, an MRI may be obtained.,2. Cholelithiasis.,3. Left basilar atelectasis.,4. A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised." }

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

{ "text_length": 1629 }

{ "text": "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." }

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

{ "text_length": 2636 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1. Left hip arthroscopic debridement.,2. Left hip arthroscopic femoral neck osteoplasty.,3. Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic. His bilateral lower extremities were placed under traction on the Hana table. His right leg was placed first. The traction post was left line, and the left leg was placed in traction. Sterile Hibiclens and alcohol prep and drape were then undertaken. A fluoroscopic localization was undertaken. Gentle traction was applied. Narrow arthrographic effect was obtained. Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization. The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum. For this reason, the acetabular articular cartilage was taken down and stabilized. This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair. The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot. After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable. The remnant articular surface of the femoral artery and acetabulum was stable. The posterior leg was stable. The traction was left half off, and the anterolateral aspect of the head and neck junction was identified. A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly. This terminated with the hip coming out of traction and indeterminable flexion. A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression. The decompression was completed with thorough irrigation of the hip. The cannula was removed, and the portals were closed using interrupted nylon. The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room. He tolerated the procedure very well with no signs of complications." }

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

{ "text_length": 2484 }

{ "text": "PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:, Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. First the trachea and the carina had normal appearance. The scope was passed into the left side and the bronchial system was found to be normal. There were scars and mucoid secretions. Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB. First, the basal lobes were explored and found to be normal. Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.," }

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

{ "text_length": 1599 }

{ "text": "PAST MEDICAL HISTORY: ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer. There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins. The fetal biometry of twin A is as follows. The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day. The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g. The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g. The following structures were seen as normal on the fetal anatomical survey. The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta. Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day. There is like gender and a single placenta. One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications. We focused our discussion today on the association of twin pregnancy with preterm delivery. We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation. We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation. These are the twins which we have the most concern regarding the long-term prospects of prematurity. We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction. We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth. We discussed the need for frequent office visits to screen for preeclampsia. We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids. I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient. I did review all of the above findings and recommendations with the patient today at the time of her visit. Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes." }

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

{ "text_length": 4481 }

{ "text": "CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS: ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints.,REVIEW OF SYSTEMS:, CONSTITUTIONAL: No fever or chills. No fatigue or weakness. HEENT: No headache. No neck pain. No eye pain or vision change. No rhinorrhea. No sinus congestion, pressure, or pain. No sore throat. No throat swelling. The patient does have the toothache on the left lower side that radiates towards his left ear as previously described. The patient does not have ear pain or hearing change. No pressure in the ear. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath. GASTROINTESTINAL: No nausea or vomiting. No abdominal pain. MUSCULOSKELETAL: No back pain. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No speech change. HEMATOLOGIC/LYMPHATIC: No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:, None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana. The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS: Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished, well developed. The patient appears to be healthy. The patient is calm, comfortable in no acute distress, looks well. The patient is pleasant and cooperative. HEENT: Head is atraumatic, normocephalic, and nontender. Eyes are normal with clear cornea and conjunctivae bilaterally. Nose, normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. Ears are normal without any sign of infection. No erythema or swelling of the canals. Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. MOUTH: The patient has a dental fracture at tooth #18. The patient states that the fracture is a couple of months old. The patient does not have any obvious dental caries. The gums are normal without any erythema, swelling, or evidence of infection. There is no fluctuance or suggestion of abscess. There is slight tenderness of the tooth #18. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion, or swelling. Mucous membranes are moist. Floor of the mouth is normal without any tenderness or swelling. No suggestion of abscess. There is no pre or post auricular lymphadenopathy either. NECK: Supple. Nontender. Full range of motion. No meningismus. No cervical lymphadenopathy. No JVD. No carotid artery or vertebral artery bruits. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally. No shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to the back, arms, or legs. The patient has normal use of the extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. No evidence of clinical intoxification. HEMATOLOGIC/LYMPHATIC: No lymphadenitis is palpated.,DIAGNOSES:,1. ACUTE LEFT JAW PAIN.,2. #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3. ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:, Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation. The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain. The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain. He was given precautions for drowsiness and driving with the use of this medication. The patient was also given a prescription for pen V. The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern." }

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

{ "text_length": 4679 }

{ "text": "REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:, \"I felt anxious yesterday.\",HPI:, A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath. The patient was consulted by Psychiatry for anxiety. I know this patient from a previous consult. During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with \"syncopal episodes.\" She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours. The patient was seen by Abc, MD, and Def, Ph.D. The laboratories were reviewed and were positive for UTI, and anemia is also present. The TSH level was within normal limits. She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety. A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:, Metastatic breast cancer to bone. The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:, The patient has a history of depression and anxiety. She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:, There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:, The patient is married and lives at home with her husband. She has a history of smoking one pack per day for 18 years. The patient quit in 1967. According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1. Klonopin 0.25 mg p.o. every evening.,2. Fluconazole 200 mg p.o. daily.,3. Synthroid 125 mcg p.o. everyday.,4. Remeron 15 mg p.o. at bedtime.,5. Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1. Tylenol 650 mg p.o. every 4 hours.,2. Klonopin 0.5 mg p.o. every 8 hours.,3. Promethazine 12.5 mg every 4 hours.,4. Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90. White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000. TSH level 0.88. The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE: The patient is dressed in a hospital gown. She is lying in bed during the interview. She is well groomed with good hygiene.,MOTOR ACTIVITY: No psychomotor retardation or agitation noted. Good eye contact.,ATTITUDE: Pleasant and cooperative.,ATTENTION AND CONCENTRATION: Normal. The patient does not appear to be distracted during the interview.,MOOD: Okay.,AFFECT: Mood congruent normal affect.,THOUGHT PROCESS: Logical and goal directed.,THOUGHT CONTENT: No delusions noted.,PERCEPTION: Did not assess.,MEMORY: Not tested.,SENSORIUM: Alert.,JUDGMENT: Good.,INSIGHT: Good.,IMPRESSION:,1. AXIS I: Possibly major depression or generalized anxiety disorder.,2. AXIS II: Deferred.,3. AXIS III: Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4. AXIS IV: Interpersonal stressors." }

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

{ "text_length": 3602 }

{ "text": "NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS: ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:, Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time. There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%). The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1. Negative for acute cholecystitis or cystic duct obstruction.,2. Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis." }

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

{ "text_length": 937 }

{ "text": "CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal.,NECK: Nontender, full range of motion, was not examined initially, a collar was placed.,HEART: Regular.,LUNGS: Clear.,CHEST/BACK/ABDOMEN: Without trauma.,SKIN: With multiple excoriations from scratching and itching.,NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment." }

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

{ "text_length": 2744 }

{ "text": "GROSS DESCRIPTION:,A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an,8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x,0.7 x 0.5 cm sessile tumor with surrounding pleural puckering.,B. Received fresh, labeled with patient's name, designated \"lymph node', is a 1.7 cm possible lymph node with anthracotic pigment.,C. Received fresh labeled with patient's name, designated 'right upper lobe', is a 16.0 x,14.5 x 6.0 cm lobe of lung. The lung is inflated with formalin. There is a 12.0 cm staple line on the lateral surface, inked blue. There is a 1.3 x 1.1 x 0.8 cm subpleural firm ill-defined mass, 2.2 cm from the bronchial margin and 1.5 cm from the previously described staple line. The overlying pleura is puckered.,D. Received fresh, labeled with patient's name, designated '4 lymph nodes', is a 2.0 x 2.0 x 2.0 cm aggregate of lymphoid material with anthracotic pigment and adipose tissue.,E. Received fresh, labeled with patient's name, designated 'subcarinal lymph node', is a,2.0 x 1.7 x 0.8 cm aggregate of lymphoid material with anthracotic pigment .,FINAL DIAGNOSIS:,A. Right upper lobe wedge lung biopsy: Poorly differentiated non-small cell carcinoma. Tumor Size: 0.8 cm. Arterial (large vessel) invasion: Not seen. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,B. Biopsy, 10R lymph node: Anthracotically pigmented lymphoid tissue, negative for malignancy.,C. Right upper lobe, lung: Moderately differentiated non-small cell carcinoma,(adenocarcinoma). Tumor Size: 1.3 cm. Arterial (large vessel) invasion: Present. Small vessel (lymphatic) invasion: Not seen. Pleural invasion: Not identified. Margins of excision: Negative for malignancy.,D. Biopsy, 4R lymph nodes: Lymphoid tissue, negative for malignancy.,E. Biopsy, subcarinal lymph node: Lymphoid tissue, negative for malignancy.,COMMENTS:, Pathologic examination reveals two separate tumors in the right upper lobe. They appear histologically distinct, suggesting they are separate primary tumors (pT1). The right upper lobe wedge biopsy (part A) shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. The right upper lobe carcinoma identified in the resection (part C) is a moderately differentiated adenocarcinoma with obvious gland formation." }

[ { "label": " Lab Medicine - Pathology", "score": 1 } ]

{ "text_length": 2508 }

{ "text": "EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison is made with the prior CT abdomen and pelvis dated 10/20/05. There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP. Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips. The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen. There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak. Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either. No exoluminal leakage is identified at any level. There is no retroperitoneal hematoma present. The findings are unchanged from the prior exam. ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present. There is advanced atrophy of the left kidney. No hydronephrosis is present. No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified. There is prominent streak artifact from the left total hip replacement. There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis. The bladder grossly appears normal. A hysterectomy has been performed. ,IMPRESSION:,1. No complications identified regarding endoluminal aortoiliac graft repair as described. The findings are stable compared to the study of 10/20/04. ,2. Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level. ,3. No other acute findings noted. ,4. Advanced left renal atrophy." }

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

{ "text_length": 2147 }

{ "text": "REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure. She is on multiple medications, unable to control the blood pressure. From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath. She complains of fatigue and tiredness. The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery. The patient is in intensive care unit.,CORONARY RISK FACTORS:, History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal. No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: ,No major surgery except for C-section.,MEDICATIONS:, Presently on Cardizem and metoprolol were discontinued. Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker. Does not consume alcohol. No history of recreational drug use.,PAST MEDICAL HISTORY:, Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL: No history of fever, rigors, or chills.,HEENT: No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR: No congestive heart. No arrhythmia.,RESPIRATORY: No history of pneumonia or valley fever.,GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena.,UROLOGIC: No frequency or urgency.,MUSCULOSKELETAL: No arthritis or muscle weakness.,SKIN: Nonsignificant.,NEUROLOGICAL: No TIA. No CVA. No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT: Atraumatic and normocephalic.,NECK: Neck veins are flat.,LUNGS: Clear.,HEART: S1 and S2 regular.,ABDOMEN: Soft and nontender.,EXTREMITIES: No edema. Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes. Labs were noted. BUN and creatinine within normal limits.,IMPRESSION:,1. Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2. No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1. We will get an echocardiogram for assessment left ventricular function.,2. The patient will start on labetalol and hydralazine to see how see fairs.,3. Based on response to medication, we will make further adjustments. Discussed with the patient regarding plan of care, fully understands and consents for the same. All the questions answered in detail." }

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

{ "text_length": 2950 }

{ "text": "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." }

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

{ "text_length": 1622 }

{ "text": "PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis, gangrenous.,PROCEDURE: , Appendectomy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room under urgent conditions. After having obtained an informed consent, he was placed in the operating room and under anesthesia. Followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion. Antibiotics had been given prior to incision. A McBurney incision was performed and it carried out through the peritoneal cavity. Immediately there was purulent material seen in the area. Samples were taken for culture and sensitivity of aerobic and anaerobic sets. The appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall. There was quite a bit of local peritonitis. The mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of Vicryl and then a Z stitch. The area was abundantly irrigated with normal saline and also the pelvis. The distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,Then the peritoneal and internal fascia were approximated with a suture of 0 Vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline. The skin was closed with a combination of a subcuticular suture of fine Monocryl followed by the application of Dermabond. The patient tolerated the procedure well. Estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.," }

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

{ "text_length": 1769 }