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+"admitting diagnoses:  left renal cell carcinoma, left renal cyst. discharge diagnosis:  left renal cell carcinoma, left renal cyst. secondary diagnoses:1.  chronic obstructive pulmonary disease.2.  coronary artery disease. procedures:  robotic-assisted laparoscopic left renal cyst decortication and cystoscopy. history of present illness:  mr. abc is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  he has undergone mri of the abdomen on june 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  of note, there are no other enhancing solid masses seen on this mri.  after discussion of multiple management strategies with the patient including:1.  left partial nephrectomy.2.  left radical nephrectomy.3.  left renal cyst decortication.  the patient is likely to undergo the latter procedure. hospital course:  the patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  the contents were aspirated and careful dissection of the cyst wall was performed.  multiple specimens of the cyst wall were sent for pathology.  approximately one liter of cystic fluid was drained during the procedure.  the renal bed was inspected for hemostasis, which appear to be adequate.  there were no complications with the procedure.  single jp drain was left in place.  additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  furthermore, no gross lesions were encountered in the bladder.  the patient left or with transfer to the pacu and subsequently to the hospital floor. the patient’s postoperative course was relatively uneventful.  his diet and activity were gradually advanced without complication.  on postoperative day #2, he was passing flatus and has had bowel movements.  his jackson-pratt drain was discontinued on postoperative day #3 that being the day of discharge.  his foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  at the time of discharge, he was afebrile.  his vital signs indicated hemodynamic stability and he had no evidence of infection.  the patient was instructed to follow up with dr. xyz on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative. disposition:  to home. discharge condition:  good. medications:  please see attached medication list. instructions:  the patient was instructed to contact dr. xyz’s office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns. followup:  the patient will follow up with dr. xyz for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.",nephrology
+"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.",cardiology
+"type of procedure:  esophagogastroduodenoscopy with biopsy. preoperative diagnosis:  abdominal pain. postoperative diagnosis:  normal endoscopy. premedication:  fentanyl 125 mcg iv, versed 8 mg iv. indications:  this healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  she has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  she was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  ultrasound was normal and a hida scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  endoscopy was requested to make sure there is not upper gi source of her pain before considering cholecystectomy. procedure:  the patient was premedicated and the olympus gif 160 video endoscope advanced to the distal duodenum.  gastric biopsies were taken to rule out helicobacter and the procedure was completed without complication. impression:  normal endoscopy. plan:  refer to a general surgeon for consideration of cholecystectomy.",gastroenterology
+"examination:  cardiac catheterization. procedure performed:  left heart catheterization, lv cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer. indication:  syncope with severe aortic stenosis. complications:  none. description of procedure:  after informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  the right groin was prepped and draped in the usual sterile fashion.  after adequate conscious sedation and local anesthesia was obtained, a 6-french sheath was placed in the right common femoral artery and a 8-french sheath was placed in the right common femoral vein.  following this, a 7.5-french swan-ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmhg.  the catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmhg.  the catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmhg.  the pulmonary arterial pressures were noted to be 31/14/21 mmhg.  following this, the catheter was removed, the sheath was flushed and a 6-french jl4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  following this, the catheter was exchanged over the guidewire for 6-french jr4 diagnostic catheter.  we were unable to cannulate the right coronary artery.  therefore, we exchanged for a williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  following this, this catheter was exchanged over a guidewire for a 6-french langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  following this, the catheters were removed.  sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-french angio-seal device.  the patient tolerated the procedure well.  there were no complications. description of findings:  the left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  the left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  the left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  there is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  the right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  the remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  the left ventricle appears to be normal sized.  the aortic valve is heavily calcified.  the estimated ejection fraction is approximately 60%.  there was 4+ mitral regurgitation noted.  the mean gradient across the aortic valve was noted to be 33 mmhg yielding an aortic valve area of 0.89 cm2. conclusion:1.  moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.2.  moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.3.  4+ mitral regurgitation. plan:  the patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to dr kenneth fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.",cardiology
+"history:  the patient is a 19-year-old boy with a membranous pulmonary atresia, underwent initial repair 12/04/1987 consisting of pulmonary valvotomy and placement of 4 mm gore-tex shunt between the ascending aorta and pulmonary artery with a snare.  this was complicated by shunt thrombosis __________ utilizing a 10-mm balloon.  resulting in significant hypoxic brain injury where he has been left with static encephalopathy and cerebral palsy.  on 04/07/1988, he underwent heart catheterization and balloon pulmonary valvuloplasty utilizing a 10-mm balloon.  he has been followed conservatively since that time.  a recent echocardiogram demonstrated possibly a significant right ventricle outflow tract obstruction with tricuspid valve regurgitation velocity predicting a right ventricular systolic pressure in excess of 180 mmhg.  right coronary artery to pulmonary artery fistula was also appreciated.  the patient underwent cardiac catheterization to assess hemodynamics associated with his current state of repair. procedure:  the patient was placed under general endotracheal anesthesia breathing on 30% oxygen throughout the case.  cardiac catheterization was performed as outlined in the attached continuation sheets.  vascular entry was by percutaneous technique, and the patient was heparinized.  monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures. using a 7-french sheath, a 6-french wedge catheter was inserted.  the right femoral vein advanced through the right heart structures out to the branch pulmonary arteries.  this catheter was then exchanged over wire for a 5-french marker pigtail catheter, which was directed into the main pulmonary artery. using a 5-french sheath, a 5-french pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  this catheter was then exchanged for a judkins right coronary catheter for selective cannulation of the right coronary artery. flows were calculated by the fick technique using a measured assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity. cineangiograms were obtained with injection of the main pulmonary artery and right coronary artery. after angiography, two normal-appearing renal collecting systems were visualized.  the catheters and sheaths were removed and topical pressure applied for hemostasis.  the patient was returned to the recovery room in satisfactory condition.  there were no complications. discussion:  oxygen consumption was assumed to be normal.  mixed venous saturation was normal with no evidence of intracardiac shunt.  left-sided heart was fully saturated.  phasic right atrial pressures were normal with an a-wave similar to the normal right ventricular end-diastolic pressure.  right ventricular systolic pressure was mildly elevated at 45% systemic level.  there was a 25 mmhg peak systolic gradient across the outflow tract to the main branch pulmonary arteries.  phasic branch pulmonary artery pressures were normal.  right-to-left pulmonary artery capillary wedge pressures were normal with an a-wave similar to the normal left ventricular end-diastolic pressure of 12 mmhg.  left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  phasic ascending and descending pressures were similar and normal.  the calculated systemic and pulmonary flows were equal and normal.  vascular resistances were normal.  angiogram with contrast injection in the main pulmonary artery showed catheter induced pulmonary insufficiency.  the right ventricle appeared mildly hypoplastic with a good contractility and mild tricuspid valve regurgitation.  there is dynamic narrowing of the infundibulum with hypoplastic pulmonary annulus.  the pulmonary valve appeared to be thin and moved well.  the median branch pulmonary arteries were of good size with normal distal arborization.  angiogram with contrast injection in the right coronary artery showed a non-dominant coronary with a small fistula arising from the proximal right coronary artery coursing over the infundibulum and entering the left facing sinus of the main pulmonary artery. initial diagnoses:1.  membranous pulmonary atresia.2.  atrial septal defect.3.  right coronary artery to pulmonary artery fistula. surgeries (interventions):  1.  pulmonary valvotomy surgical.2.  aortopulmonary artery central shunt.3.  balloon pulmonary valvuloplasty. current diagnoses:  1.  pulmonary valve stenosis supplemented to hypoplastic pulmonary annulus.2.  mild right ventricle outflow tract obstruction due to supple pulmonic narrowing.3.  small right coronary artery to main pulmonary fistula.4.  static encephalopathy.5.  cerebral palsy. management:  the case to be discussed with combined cardiology/cardiothoracic surgery case conference.  given the mild degree of outflow tract obstruction in this sedentary patient, aggressive intervention is not indicated.  conservative outpatient management is to be recommended.  further patient care will be directed by dr. x.",pulmonary disease
+"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.",pulmonary disease
+"preoperative diagnosis:  blood loss anemia. postoperative diagnoses:1.  diverticulosis coli.2.  internal hemorrhoids.3.  poor prep. procedure performed:  colonoscopy with photos. anesthesia:  conscious sedation per anesthesia. specimens:  none. history:  the patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  she underwent an egd and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  a coloscopy is now being performed for completion. 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 sedation by the anesthesia department.  a digital rectal exam was performed and there was no evidence of mass.  the colonoscope was then inserted into the rectum.  there was some solid stool encountered.  the scope was maneuvered around this.  there was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  the scope was then passed through the transverse colon and ascending colon to the cecum.  no masses or polyps were noted.  visualization of the portions of the colon was however somewhat limited.  there were scattered diverticuli noted in the sigmoid. the scope was slowly withdrawn carefully examining all walls.  once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  the scope was then completely withdrawn.  the patient tolerated the procedure well and was transferred to recovery room in stable condition.  she will be placed on a high-fiber diet and colace and we will continue to monitor her hemoglobin.",gastroenterology
+"procedure:  esophagogastroduodenoscopy with gastric biopsies. indication:  abdominal pain. findings:  antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion. medications:  fentanyl 200 mcg and versed 6 mg. scope:  gif-q180. procedure detail:  following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  questions were answered.  pause preprocedure was performed. following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  the esophagus appeared to have normal motility and mucosa.  regular z line was located at 44 cm from incisors.  no erosion or ulceration.  no esophagitis. upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  there was pyloric channel and antral erythema, but no visible erosion or ulceration.  there was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  this was biopsied and was placed separately in bottle #2.  random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  no active ulceration was found. upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  postbulbar duodenum looked normal. the patient was assessed upon completion of the procedure.  okay to discharge once criteria met. follow up with primary care physician. i met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  await biopsy results.",gastroenterology
+"exam:  ultrasound abdomen, complete. history:  38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  the patient has diffuse abdominal pain.  there is a history of aids. technique:  an ultrasound examination of the abdomen was performed. findings:  the liver has normal echogenicity.  the liver is normal sized.  the gallbladder has a normal appearance without gallstones or sludge.  there is no gallbladder wall thickening or pericholecystic fluid.  the common bile duct has a normal caliber at 4.6 mm.  the pancreas is mostly obscured by gas.  a small portion of the head of pancreas is visualized which has a normal appearance.  the aorta has a normal caliber.  the aorta is smooth walled.  no abnormalities are seen of the inferior vena cava.  the right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  no masses, cysts, calculi, or hydronephrosis is seen.  there is normal renal cortical echogenicity.  the spleen is somewhat prominent with a maximum diameter of 11.2 cm.  there is no ascites.  the urinary bladder is distended with urine and shows normal wall thickness without masses.  the prostate is normal sized with normal echogenicity. impression:  1.  spleen size at the upper limits of normal.2.  except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  the visualized portion of the head had a normal appearance.3.  the gallbladder has a normal appearance without gallstones.  there are no renal calculi.",gastroenterology
+"preoperative diagnoses1.  acute appendicitis.2.  29-week pregnancy. postoperative diagnoses1.  acute appendicitis.2.  29-week pregnancy. operation:  appendectomy. description of the procedure:  after obtaining the informed consent including all risks and benefits of the procedure, the patient was urgently taken to the operating room where a spinal anesthetic was given and the patient’s abdomen was prepped and draped in a usual fashion.  preoperative antibiotics were given.  a time-out process was followed.  local anesthetics were infiltrated in the area of the proposed incision.  a modified mcburney incision was performed.  a very abnormal appendix was immediately found.  there was a milky fluid around the area and this was cultured both for aerobic and anaerobic cultures.  the distal end of the appendix had transformed itself into an abscess.  the proximal portion was normal.  the appendix was very friable and a no-touch technique was used.  it was carefully dissected off the cecum, and then it was ligated and excised after the mesoappendix had been taken care of.  then the stump was buried with a pursestring of 2-0 vicryl.  the operative area was abundantly irrigated with warm saline and then closed in layers.  the layer was further irrigated.  a subcuticular suture of monocryl was performed in the skin followed by the application of dermabond. further local anesthetic was infiltrated at the end of the procedure in the operative area and the patient tolerated the procedure well, and with an estimated blood loss that was not consequential, was transferred from recovery to icu in a satisfactory condition.",gastroenterology
+"exam:  renal ultrasound. history:  renal failure, neurogenic bladder, status-post cystectomy. technique:  multiple ultrasonographic images of the kidneys were obtained in the transverse and longitudinal planes. comparison:  most recently obtained mm/dd/yy. findings:  the right kidney measures 12 x 5.2 x 4.6 cm and the left kidney measures 12.2 x 6.2 x 4.4 cm.  the imaged portions of the kidneys fail to demonstrate evidence of mass, hydronephrosis or calculus.  there is no evidence of cortical thinning. incidentally there is a rounded low-attenuation mass within the inferior aspect of the right lobe of the liver measuring 2.1 x 1.5 x 1.9 cm which has suggestion of some peripheral blood flow. impression:1.  no evidence of hydronephrosis.2.  mass within the right lobe of the liver.  the patient apparently has a severe iodine allergy.  further evaluation with mri is recommended.3.  the results of this examination were given to xxx in dr. xxx office on mm/dd/yy at xxx",nephrology
+"history of present illness:  the patient is a 63-year-old white male who was admitted to the hospital with chf and lymphedema.  he also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of ca of the lung.  this consultation was made for better control of his blood sugars.  on questioning, the patient says that he does not have diabetes.  he says that he has never been told about diabetes except during his last admission at jefferson hospital.  apparently, he was started on glipizide at that time.  his blood sugars since then have been good and he says when he went back to jefferson three weeks later, he was told that he does not have a sugar problem.  he is not sure.  he is not following any specific diet.  he says "my doctor wants me to lose 30-40 pounds in weight" and he would not mind going on a diet.  he has a long history of numbness of his toes.  he denies any visual problems. past medical history:  as above that includes ca of the lung, copd, bilateral cataracts.  he has had chronic back pain.  there is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown. social history:  the patient has been a smoker since the age of 10.  so, he was smoking 2-3 packs per day.  since being started on chantix, he says he has cut it down to half a pack per day.  he does not abuse alcohol. medications: 1.  glipizide 5 mg p.o. daily.2.  theophylline.3.  z-pak.4.  chantix.5.  januvia 100 mg daily.6.  k-lor.7.  oxycontin.8.  flomax.9.  lasix.10.  advair.11.  avapro.12.  albuterol sulfate.13.  vitamin b tablet.14.  oxycontin and oxycodone for pain. family history:  positive for diabetes mellitus in the maternal grandmother. review of systems:  as above.  he says he has had numbness of toes for a long time.  he denies any visual problems.  his legs have been swelling up from time to time for a long time.  he also has history of copd and gets short of breath with minimal activity.  he is also not able to walk due to his weight.  he has had ulcers on his legs, which he gets discharge from.  he has chronic back pain and takes oxycontin.  he denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  there is no chest pain.  he does get short of breath on walking. physical examination:the patient is a well-built, obese, white male in no acute distress.vital signs:  pulse rate of 89 per minute and regular.  blood pressure of 113/69, temperature is 98.4 degrees fahrenheit, and respirations are 18.heent:  head is normocephalic and atraumatic.  eyes, perrla.  eoms intact.  fundi were not examined.neck:  supple.  jvp is low.  trachea central.  thyroid small in size.  no carotid bruits.heart:  shows normal sinus rhythm with s1 and s2.lungs:  show bilateral wheezes with decreased breath sounds at the bases.abdomen:  soft and obese.  no masses.  bowel sounds are present.extremities:  show bilateral edema with changes of chronic venostasis.  he does have some open weeping sores.  pulses could not be palpated due to leg swelling. impression/plan:1.  diabetes mellitus, type 2, new onset.  at this time, the patient is on januvia as well as glipizide.  his blood sugar right after eating his supper was 101.  so, i am going to discontinue glipizide, continue on januvia, and add no-concentrated sweets to the diet.  we will continue to follow his blood sugars closely and make adjustments as needed.2.  neuropathy, peripheral, query etiology.  we will check tsh and b12 levels.3.  lymphedema.4.  recurrent cellulitis.5.  obesity, morbid.6.  tobacco abuse.  he was encouraged to cut his cigarettes down to 5 cigarettes a day.  he says he feels like smoking after meals.  so, we will let him have it after meals first thing in the morning and last thing at night.7.  chronic venostasis.8.  lymphedema.  we would check his lipid profile also.9.  hypertension.10.  backbone pain, status post back surgery.11.  status post hernia repair.12.  status post penile implant and removal.13.  umbilical hernia repair.",cardiology
+"abnormal cholesterol result letter recently you had a cholesterol test done.  the cholesterol levels were abnormal.  these are usually associated with increased risk for stroke and heart attack.  i am writing this letter to you to let you know that your levels are high enough that i think intervention is the next best step.  i would like you to make an appointment, if you are interested in treatment for this.  there are several treatment options available at this time.  diet is one of the options, although there is limited reduction in total cholesterol and ldl cholesterol with dieting.  most of the time under strict diet patients can achieve a 15% reduction in cholesterol.  if your cholesterol levels are moderate to severely elevated, usually diet is not the first line of therapy.  if you are diabetic or have hypertension these two also increase your risk with the combination of hypercholesterolemia.  most of the time cholesterol that is elevated is from your genetic background and is independent of diet.  new research shows that treatment of high cholesterol can decrease your risk of developing alzheimer",gastroenterology
+"identifying data:  the patient is a 40-year-old white male.  he is married, on medical leave from his job as a tree cutter, and lives with his wife and five children. chief complaint and reaction to hospitalization:  the patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at hospital emergency room, the morning prior to admission. history of present illness:  the patient was very sleepy this morning, only minimally cooperative with interview.  additional information taken from the emergency room records that accompanied him from hospital yesterday as well as from his wife, who i contacted by telephone.  the patient was apparently at his stable baseline when discharged from the hospital on 01/21/10, status post back surgery following a work-related injury.  the patient returned to emergency room on the evening prior to admission complaining of severe back pain.  his er course is notable for yelling, spitting, and striking multiple staff members.  the patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to mhps, who subsequently detained him for 72 hours for dangerousness to others.  on interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications.  he was contrite about the violence.  when his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years. his wife reports that after discharge from the hospital, on 01/21/10, he was prescribed percocet, soma, hydroxyzine, and valium.  he essentially exhausted his approximately 10 days’ supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday.  she reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." she denies feeling that he currently represents a threat to her or her five children.  she was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago. past psychiatric history:  the patient has a history of involuntary treatment act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review.  the patient denies any outpatient mental health treatment before or since this hospitalization.  he describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication. past medical history:  notable for status post back surgery, discharged from hospital on 01/21/10. medications:  from discharge from hospital on 01/21/10, include percocet, valium, soma, and vistaril, doses and frequency are not currently known.  his wife reports that he was discharged with approximately 10 days’ supply of these agents. social and developmental history:  the patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury.  he lives with his wife and children.  he has a history of domestic violence, but not recently.  other details of occupational, educational history not currently known. substance and alcohol history:  records indicate a previous history of methamphetamine and alcohol abuse/dependence.  the wife states that he has not consumed either since 12/07.  of note, urine tox screen at hospital was positive for marijuana. legal history:  the patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years.  it is not known whether the patient is currently on probation. genetic psychiatric history:  unknown. mental status examination:attitude:  the patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.appearance: he is unkempt and there are multiple visible tattoos on his biceps.psychomotor:  there is no obvious psychomotor agitation or retardation.  there are no obvious extrapyramidal symptoms of tardive dyskinesia.affect:  his affect is notably restricted probably due to the fact that he is sleepy.mood:  describes his mood as "okay."speech:  speech is normal rate, volume, and tone.thought processes:  his thought processes appear to be linear.thought content:  his thought content is notable for his expressions of contrition about violence at hospital last night.  he denies suicidal or homicidal ideation.cognitive assessment:  cognitively, he is alert and oriented to person, place, and date but not situation.  attributes this to not really remembering the events at hospital that resulted in this hospitalization.judgment and insight:  his insight and judgment are both appear to be improving.assets:  include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.limitations:  include his back injury and possible need for improvement of health treatment engagement. formulation:  this is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, soma, hydroxyzine, and valium.  he appears much improved from his condition at hospital last night and i suspect that his behavior is most likely attributed to delirium and this since resolved.  he reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review. diagnoses:axis i:  delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, soma, valium, and hydroxyzine.)  rule out bipolar affective disorder.axis ii:  deferred.axis iii:  chronic pain status post back surgery.axis iv:  appears to be moderate.  he is currently on medical leave from his job.axis v:  global assessment of functioning is currently 50 (his gaf was 20 approximately 24 hours ago). estimated length of stay:  three days. plan:  i will hold psychiatric medications for now given the patient’s fairly rapid improvement as he cleared from the condition, i suspect is likely due to misuse of prescribed medications.  the patient will be placed on ciwa protocol given that one of the medications he overused was valium.  of note, he does not currently appear to be withdrawing and i anticipate that his ciwa will be discontinued prior to discharge.  i would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care.  the internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.",psychiatry
+description:1.  normal cardiac chambers size.2.  normal left ventricular size.3.  normal lv systolic function.  ejection fraction estimated around 60%.4.  aortic valve seen with good motion.5.  mitral valve seen with good motion.6.  tricuspid valve seen with good motion.7.  no pericardial effusion or intracardiac masses. doppler:1.  trace mitral regurgitation.2.  trace tricuspid regurgitation. impression:1.  normal lv systolic function.2.  ejection fraction estimated around 60%.,cardiology
+"preoperative diagnosis:  appendicitis. postoperative diagnosis:  appendicitis, nonperforated. procedure performed:  appendectomy. anesthesia:  general endotracheal. procedure:  after informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  general endotracheal anesthesia was induced without incident.  the patient was prepped and draped in the usual sterile manner. a transverse right lower quadrant incision was made directly over the point of maximal tenderness.  sharp dissection utilizing bovie electrocautery was used to expose the external oblique fascia.  the fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  the internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  the transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean. the cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  after the appendix was fully visualized, the mesentery was divided between kelly clamps and ligated with 2-0 vicryl ties.  the base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  the base was ligated with 2-0 vicryl tie over the crushed area, and the appendix amputated along the clamp.  the stump of the appendix was cauterized and the cecum was returned to the abdomen. the peritoneum was irrigated with warm sterile saline.  the mesoappendix and cecum were examined for hemostasis which was present.  the wound was closed in layers using 2-0 vicryl for the peritoneum and 0 vicryl for the internal oblique and external oblique layers.  the skin incision was approximated with 4-0 monocryl in a subcuticular fashion.  the skin was prepped with benzoin, and steri-strips were applied.  a dressing was placed on the wound.  all surgical counts were reported as correct. having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",gastroenterology
+"this is a 95.5-hour continuous video eeg monitoring study. technical summary:  the patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  the patient was recorded digitally using the 10-20 system of electrode placement.  additional temporal electrodes and single channels of eog and ekg were also recorded.  the patient’s medications valproic acid, zonegran, and keppra were weaned progressively throughout the study. the occipital dominant rhythm is 10 to 10.5 hz and well regulated.  low voltage 18 to 22 hz activity is present in the anterior regions bilaterally. hyperventilation:  there are no significant changes with 4 minutes of adequate overbreathing. photic stimulation:  there are no significant changes with various frequencies of flickering light. sleep:  there are no focal or lateralizing features and no abnormal waveforms. induced event:  on the final day of study, a placebo induction procedure was performed to induce a clinical event.  the patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  at 1:38 p.m., the patient was instructed to begin hyperventilation.  approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  she persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  when asked what had just occurred, she replied that she was asleep and did not remember any event.  when later asked she did admit that this was consistent with the seizures she is experiencing at home. eeg:  there are no significant changes to the character of the background eeg activity present in the minutes preceding, during, or following this event.  of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present. impression:  the findings of this patient’s 95.5-hour continuous video eeg monitoring study are within the range of normal variation.  no epileptiform activity is present.  one clinical event was induced with hyperventilation and photic stimulation.  the clinical features of this event are described in the technical summary above.  there was no epileptiform activity associated with this event.  this finding is consistent with a non-epileptic pseudoseizure.",neurology
+"history of present illness:  the patient is a 68-year-old woman whom i have been following, who has had angina.  in any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when i spoke to her.  i advised her to call 911, which she did.  while waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  by the time she presented here, she is currently pain-free and is feeling well. past cardiac history:  the patient has been having arm pain for several months.  she underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  i had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  however, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  on 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid lad lesion, circumflex normal, and rca totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  the decision was made to transfer  her as she may be having collateral insufficiency from the lad stenosis to the rca vessel.  she underwent that with drug-eluting stents on 08/16/08, with i believe three or four total placed, and was discharged on 08/17/08.  she had some left arm discomfort on 08/18/08, but this was mild.  yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  this is her usual angina.  she is being admitted with unstable angina post stent. past medical history:  longstanding hypertension, cad as above, hyperlipidemia, and overactive bladder. medications:1.  detrol la 2 mg once a day.2.  prilosec for gerd 20 mg once a day.3.  glucosamine 500/400 mg once a day for arthritis.4.  multivitamin p.o. daily.5.  nitroglycerin sublingual as available to her.6.  toprol-xl 25 mg once a day which i started although she had been bradycardic, but she seems to be tolerating.7.  aspirin 325 mg once a day.8.  plavix 75 mg once a day.9.  diovan 160 mg once a day.10.  claritin 10 mg once a day for allergic rhinitis.11.  norvasc 5 mg once a day.12.  lipitor 5 mg once a day.13.  evista 60 mg once a day. allergies:  allergies to medications are none.  she denies any shrimp or sea food allergy. family history:  her father died of an mi in his 50s and a brother had his first mi and bypass surgery at 54. social history:  she does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  she is divorced and lives alone and is a retired laboratory technician from cornell diagnostic laboratory. review of systems:  she denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  no morning headaches or fatigue.  no psychiatric diagnosis.  no psoriasis, no lupus.  remainder of the review of systems is negative x14 systems except as described above. physical examination:general:  she is a pleasant elderly woman, currently in no acute distress.vital signs:  height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and o2 saturation 100%heent:  cranium is normocephalic and atraumatic.  she has moist mucosal membranes.neck:  veins are not distended.  there are no carotid bruits.lungs:  clear to auscultation and percussion without wheezes.heart:  s1 and s2, regular rate.  no significant murmurs, rubs or gallops.  pmi nondisplaced.abdomen:  soft and nondistended.  bowel sounds present.extremities:  without significant clubbing, cyanosis or edema.  pulses grossly intact.  bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for pci and there is no evidence of hematoma or bruit and intact distal pulses. laboratory data:  ekg reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease. sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  bun 16 and creatinine 0.9.  glucose 110.  magnesium 2.5.  alt 107 and ast 65 and these were normal on 08/15/08.  inr is 0.89, ptt 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000. impression and plan:  the patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  in any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, i am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  we will continue her beta-blocker and i cannot increase the dose because she is bradycardic already.  aspirin, plavix, valsartan, lipitor, and norvasc.  i am going to add imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out mi, although there is a little suspicion.  i suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  my concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal lv function.  she will continue the glucosamine for her arthritis, claritin for allergies, and detrol la for urinary incontinence. total patient care time in the emergency department 75 minutes.  all this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  the patient desires full resuscitation status.",cardiology
+"preoperative diagnosis: tachybrady syndrome. postoperative diagnosis: tachybrady syndrome. operative procedure: insertion of transvenous pacemaker. anesthesia: local procedure and gross findings: the patient’s chest was prepped with betadine solution and a small amount of lidocaine infiltrated.  in the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. fluoroscopy confirmed the presence of the wire in the superior vena cava.  an introducer was then placed over the wire.  the wire was removed and replace by a ventricular lead that was seated under fluoroscopy. following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.   the subcutaneous tissues were irrigated and closed with interrupted 4-o vicryl, and the skin was closed with staples.  sterile dressings were placed, and the patient was returned to the icu in good condition.",cardiology
+"reason for consultation:  we were asked to see the patient in regards to a brain tumor. history of present illness: she was initially diagnosed in september of this year with a glioblastoma multiforme.  she presented with several lesions in her brain and a biopsy confirmed the diagnosis.  she was seen by dr. x in our group.  because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  details of her treatment are not available at the time of this dictation.  her family has a packet of temodar 100-mg pills.  she is admitted now with increasing confusion.  a ct shows increase in size of the lesions compared to the preoperative scan.  we are asked to comment on her treatment at this point.  she herself is confused and is unable to provide further history.   past medical history:  from her old chart:  no known past medical history prior to the diagnosis. social history:  she was living alone and is now living in assisted living.   medications1.  dilantin 300 mg daily.2.  haloperidol 1 mg h.s.3.  dexamethasone 4 mg q.i.d. 4.  docusate 100 mg b.i.d.5.  pen-vk 500 mg daily.6.  ibuprofen 600 mg daily.7.  zantac 150 mg twice a day.8.  temodar 100 mg daily.9.  magic mouthwash daily.10.  tylenol #3 as needed. review of systems:  unable. physical examinationgeneral:  elderly woman, confused.  heent:  normal conjunctivae.  ears and nose normal.  mouth normal.neck:  supple.chest: clear.heart:  normal.abdomen: soft, positive bowel sounds.neurologic:  alert, cranial nerves intact.  left arm slightly weak.  left leg slightly weak. impression and plan:  glioblastoma multiforme, uncertain as to where she is in cancer treatment.  given the number of pills in the patient’s family’s hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  we will have to talk with dr. y in the clinic to get a better handle on her treatment regimen.  at this point, i will hold temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.",neurology
+"chief complaint:  "a lot has been thrown at me." the patient is interviewed with husband in room. history of present illness:  this is a 69-year-old caucasian woman with a history of huntington disease, who presented to hospital four days ago after an overdose of about 30 haldol tablets 5 mg each and tylenol tablet 325 mg each, 40 tablets.  she has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  the patient states she had been thinking about suicide for a couple of weeks.  felt that her huntington disease had worsened and she wanted to spare her family and husband from trouble.  reports she has been not socializing with her family because of her worsening depression.  husband notes that on monday after speaking to dr. x, they had been advised to alternate the patient’s pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  they did as they have instructed and husband feels this may have had some factor on her worsening depression.  the patient decided to ingest the pills when her husband went to work on friday.  she thought friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  her husband left around 7 in the morning and returned around 11 and found her sleeping.  about 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital. she says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the huntington gene.  she does not clearly explain how this has made her suicidality subside. this is the third suicide attempt in the last two months for this patient.  about two months ago, the patient took an overdose of tylenol and some other medication, which the husband and the patient are not able to recall.  she was taken to southwest memorial hermann hospital.  a few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  husband locked the gun after that and she was taken to bellaire hospital.  the patient has had three psychiatric admissions in the past two months, two to southwest memorial and one to bellaire hospital for 10 days.  she sees dr. x once or twice weekly.  he started seeing her after her first suicide attempt. the patient’s husband and the patient state that until march 2009, the patient was independent, was driving herself around and was socially active.  since then she has had worsening of her huntington symptoms including short-term memory loss.  at present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  the patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her huntington disease. the patient’s mother passed away 25 years ago from huntington’s.  her grandmother passed away 50 years ago and two brothers also passed away of huntington’s.  the patient has told her husband that she does not want to go that way.  the patient denies auditory or visual hallucinations, denies paranoid ideation.  the husband and the patient deny any history of manic or hypomanic symptoms in the past. past psychiatric history:  as per the hpi, this is her third suicide attempt in the last two months and started seeing dr. x.  she has a remote history of being on lexapro for depression. medications:  her medications on admission, alprazolam 0.5 mg p.o. b.i.d., artane 2 mg p.o. b.i.d., haldol 2.5 mg p.o. t.i.d., norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  husband has stated that the patient’s chorea becomes better when she takes haldol.  alprazolam helps her with anxiety symptoms. past medical history:  huntington disease, symptoms of dementia and hypertension.  she has an upcoming appointment with the neurologist.  currently, does have a primary care physician and _______ having an outpatient psychiatrist, dr. x, and her current neurologist, dr. y. allergies:  codeine and keflex. family medical history:  strong family history for huntington disease as per the hpi.  mother and grandmother died of huntington disease.  two young brothers also had huntington disease. family psychiatric history:  the patient denies history of depression, bipolar, schizophrenia, or suicide attempts. social history:  the patient lives with her husband of 48 years.  she used to be employed as a registered nurse.  her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  she rarely drinks socially.  she denies any illicit substance usage.  her husband reportedly gives her medication daily.  has been proactive in terms of seeking mental health care and medical care.  the patient and husband report that from march 2009, she has been relatively independent, more socially active. mental status exam:  this is an elderly woman appearing stated age.  alert and oriented x4 with poor eye contact.  appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  she is cooperative.  her speech is of low volume and slow rate and rhythm.  her mood is sad.  her affect is constricted.  her thought process is logical and goal-directed.  her thought content is negative for current suicidal ideation.  no homicidal ideation.  no auditory or visual hallucinations.  no command auditory hallucinations.  no paranoia.  insight and judgment are fair and intact. laboratory data:  a ct of the brain without contrast, without any definite evidence of acute intracranial abnormality.  u-tox positive for amphetamines and tricyclic antidepressants.  acetaminophen level 206.7, alcohol level 0.  the patient had a leukocytosis with white blood cell of 15.51, initially tsh 1.67, t4 10.4. assessment:  this is a 69-year-old white woman with huntington disease, who presents with the third suicide attempt in the past two months.  she took 30 tablets of haldol and 40 tablets of tylenol.  at present, the patient is without suicidal ideation.  she reports that her worsening depression has coincided with her worsening huntington disease.  she is more hopeful today, feels that she may be able to get help with her depression. the patient was admitted four days ago to the medical floor and has subsequently been stabilized.  her liver function tests are within normal limits. axis i:  major depressive disorder due to huntington disease, severe.  cognitive disorder, nos.axis ii:  deferred.axis iii:  hypertension, huntington disease, status post overdose.axis iv:  chronic medical illness.axis v:  30. plan1.  safety.  the patient would be admitted on a voluntary basis to main-7 north.  she will be placed on every 15-minute checks with suicidal precautions.2.  primary psychiatric issues/medical issues.  the patient will be restarted as per written by the consult service for prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, haldol 2 mg p.o. q.8h., artane 2 mg p.o. daily, xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.3.  substance abuse.  no acute concern for alcohol or benzo withdrawal.4.  psychosocial.  team will update and involve family as necessary. disposition:  the patient will be admitted for evaluation, observation, treatment.  she will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  we will place occupational therapy consult and social work consults.",neurology
+"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",neurology
+"subjective:  review of the medical record shows that the patient is a 97-year-old female patient who has been admitted and has been treated for community acquired pneumonia along with copd exacerbation.  the patient does have a longstanding history of copd.  however, she does not use oxygen at her independent assisted living home.  yesterday, she had made improvement since being here at the hospital.  she needed oxygen.  she was tested for home o2 and qualified for it yesterday also.  her lungs were very tight.  she did have wheezes bilaterally and rhonchi on the right side mostly.  she appeared to be a bit weak and although she was requesting to be discharged home, she did not appear to be fit for it. overnight, the patient needed to use the rest room.  she stated that she needed to urinate.  she awoke, decided not to call for assistance.  she stated that she did have her nurse call light button next to her and she was unable to gain access to her walker.  she attempted to walk to the rest room on her own.  she sustained a fall.  she stated that she just felt weak.  she bumped her knee and her elbow.  she had femur x-rays, knee x-rays also.  there was possibility of subchondral fracture and some swelling of her suprapatellar bursa on the right side.  this morning, she denied any headache, back pain or neck pain.  she complained mostly of right anterior knee pain for which she had some bruising and swelling. objective:vital signs:  the patient’s max temperature over the past 24 hours was 36.5; her blood pressure is 148/77, her pulse is 87 to 106.  she is 95% on 2 l via nasal cannula.heart:  regular rate and rhythm without murmur, gallop or rub.lungs:  reveal no expiratory wheezing throughout.  she does have some rhonchi on the right mid base.  she did have a productive cough this morning and she is coughing green purulent sputum finally.abdomen:  soft and nontender.  her bowel sounds x4 are normoactive.neurologic:  she is alert and oriented x3.  her pupils are equal and reactive.  she has got a good head and facial muscle strength.  her tongue is midline.  she has got clear speech.  her extraocular motions are intact.  her spine is nontender on palpation from neck to lumbar spine.  she has good range of motion with regard to her shoulders, elbows, wrists and fingers.  her grip strengths are equal bilaterally.  both elbows are strong from extension to flexion.  her hip flexors and extenders are also strong and equal bilaterally.  extension and flexion of the knee bilaterally and ankles also are strong.  palpation of her right knee reveals no crepitus.  she does have suprapatellar inflammation with some ecchymosis and swelling.  she has got good joint range of motion however.skin:  she did have a skin tear involving her right forearm lateral, which is approximately 2 to 2.5 inches in length and is at this time currently steri-stripped and wrapped with coban and is not actively bleeding. assessment:1.  acute on chronic copd exacerbation.2.  community acquired pneumonia both resolving.  however, she may need home o2 for a short period of time.3.  generalized weakness and deconditioning secondary to the above.  also sustained a fall secondary to instability and not using her walker or calling for assistance.  the patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed. plan:1.  i will have pt and ot evaluate the patient and give recommendation to safety and appliance use at home i.e. walker.  myself and one of her daughter’s spoke today about the fact that she generally lives independently at the brooke and she may need assisted living along with physical therapy and oxygen for a period of time rather than going back to independent living.2.  we will obtain an orthopedic consult secondary to her fall to evaluate her x-rays and function.",pulmonary disease
+"reason for transfer:  need for cardiac catheterization done at abcd. transfer diagnoses:1.  coronary artery disease.2.  chest pain.3.  history of diabetes.4.  history of hypertension.5.  history of obesity.6.  a 1.1 cm lesion in the medial aspect of the right parietal lobe.7.  deconditioning. consultations:  cardiology. procedures:1.  echocardiogram.2.  mri of the brain.3.  lower extremity duplex ultrasound. hospital course:  please refer to my h&p for full details.  in brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  he was brought in by a friend.  the friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  he apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  his vital signs were stable on admission.  he was ruled out for myocardial infarction with troponin x2.  an echocardiogram showed concentric lvh with an ef of 62%.  i had cardiology come to see the patient, who reviewed the records from fountain valley.  based on his stress test in the past, dr. x felt the patient needed to undergo a cardiac cath during his inpatient stay. the patient on initial presentation complained of, what sounded like, amaurosis fugax.  i performed an mri, which showed a 1 cm lesion in the right parietal lobe.  i was going to call neurology at xyz for evaluation.  however, secondary to his indication for transfer, this could be followed up at abcd with dr. y. the patient is now stable for transfer for cardiac cath. discharged to abcd. discharge condition:  stable. discharge medications:1.  aspirin 325 mg p.o. daily.2.  lovenox 40 mg p.o. daily.3.  regular insulin sliding scale.4.  novolin 70/30, 15 units b.i.d.5.  metformin 500 mg p.o. daily.6.  protonix 40 mg p.o. daily. discharge followup:  followup to be arranged at abcd after cardiac cath.",cardiology
+"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.",gastroenterology
+"the patient was sedated with intravenous fentanyl 75 mcg and intravenous versed, 5 mg, both titrated over the first ten minutes of the procedure time to achieve adequate sedation for the procedure.  cetacaine spray was applied to the hypopharynx for local anesthesia.  the upper endoscope was passed,without difficulty, into the upper gi tract.  the anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  all structures were visually normal in appearance.  biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  the endoscope and insufflated air were slowly removed from the upper gi tract.  a repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites. the patient tolerated the procedure with excellent comfort and stable vital signs.  after a recovery period in the endoscopy suite, the patient is discharged to continue recovering in the family’s care at home.  the family knows to follow up with me today if there are concerns about the patient’s recoveryfrom the procedure.  they will follow up with me later this week for biopsy and clo test results so that appropriate further diagnostic and therapeutic plans can be made.",gastroenterology
+"procedure performed:  colonoscopy and biopsy. indications:  the patient is a 50-year-old female who has had a history of a nonspecific colitis, who was admitted 3 months ago at hospital because of severe right-sided abdominal pains, was found to have multiple ulcers within the right colon, and was then readmitted approximately 2 weeks later because of a cecal volvulus, and had a right hemicolectomy.  since then, she has had persistent right abdominal pains, as well as diarrhea, with up to 2-4 bowel movements per day.  she has had problems with recurrent seizures and has been seen by dr. xyz, who started her recently on methadone. medications:  fentanyl 200 mcg, versed 10 mg, phenergan 25 mg intravenously given throughout the procedure. instrument:  pcf-160l. procedure report:  informed consent was obtained from the patient, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications, as well as the possibility of missing polyps within the colon. a colonoscope was then passed through the rectum, all the way toward the ileal colonic anastomosis, seen within the proximal transverse colon.  the distal ileum was examined, which was normal in appearance.  random biopsies were obtained from the ileum and placed in jar #1.  random biopsies were obtained from the normal-appearing colon and placed in jar #2.  small internal hemorrhoids were noted within the rectum on retroflexion. complications:  none. assessment:1.  small internal hemorrhoids.2.  ileal colonic anastomosis seen in the proximal transverse colon.3.  otherwise normal colonoscopy and ileum examination. plan: followup results of biopsies.  if the biopsies are unremarkable, the patient may benefit from a trial of tricyclic antidepressants, if it’s okay with dr. xyz, for treatment of her chronic abdominal pains.",gastroenterology
+"procedures:1.  chest x-ray on admission, no acute finding, no interval change.2.  ct angiography, negative for pulmonary arterial embolism.3.  nuclear myocardial perfusion scan, abnormal.  reversible defect suggestive of ischemia, ejection fraction of 55%. diagnoses on discharge:1.  chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.2.  coronary artery disease, abnormal nuclear scan, discussed with cardiology dr. x, who recommended to discharge the patient and follow up in the clinic.3.  diabetes mellitus type 2.4.  anemia, hemoglobin and hematocrit stable.5.  hypokalemia, replaced.6.  history of coronary artery disease status post stent placement 2006-2008.7.  bronchitis. hospital course:  the patient is a 65-year-old american-native indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, copd, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea.  the patient started on iv steroid, bronchodilator as well as antibiotics. he also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea.  he was evaluated by cardiology dr. x, who proceeded with stress test.  stress test reported positive for reversible ischemia, but cardiology decided to follow up the patient in the clinic.  the patient’s last cardiac cath was in 2008. the patient clinically significantly improved and wants to go home.  his hemoglobin on admission was 8.8, and has remained stable.  he is afebrile, hemodynamically stable. allergies:  lisinopril and penicillin. medications on discharge:1.  prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.2.  levaquin 750 mg p.o. daily for 5 more days.3.  protonix 40 mg p.o. daily.4.  the patient can continue other current home medications at home. followup appointments:1.  recommend to follow up with cardiology dr. x’s office in a week.2.  the patient is recommended to see hematology dr. y in the office for workup of anemia.3.  follow up with primary care physician’s office tomorrow. special instructions:1.  if increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.2.  discussed about discharge plan, instructions with the patient by bedside.  he understands and agreed.  also discussed discharge plan instructions with the patient’s nurse.",pulmonary disease
+"chief complaint:  worsening seizures. history of present illness:  a pleasant 43-year-old female with past medical history of cp since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  the patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  she lives in assisted living.  she has been falling more frequently.  the patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  there was no head trauma, but apparently she was doing that many times and there was no responsiveness.  the patient has no memory of the event.  she is now back to her baseline.  she states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  she is on carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  the patient is admitted for emu monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome. past medical history:  include dyslipidemia and hypertension. family history:  positive for stroke and sleep apnea. social history:  no smoking or drinking.  no drugs. medications at home:  include, avapro, lisinopril, and dyslipidemia medication, she does not remember. review of systems:  the patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  the patient also has excessive daytime sleepiness with eds of 16. physical examination:vital signs:  last blood pressure 130/85, respirations 20, and pulse 70.general:  normal.neurological:  as follows.  right-handed female, normal orientation, normal recollection to 3 objects.  the patient has underlying mr. speech, no aphasia, no dysarthria.  cranial nerves, funduscopic intact without papilledema.  pupils are equal, round, and reactive to light.  extraocular movements intact.  no nystagmus.  her mood is intact.  symmetric face sensation.  symmetric smile and forehead.  intact hearing.  symmetric palate elevation.  symmetric shoulder shrug and tongue midline.  motor 5/5 proximal and distal.  the patient does have limp on the right lower extremity.  her babinski is hyperactive on the left lower extremity, upgoing toes on the left.  sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  the patient has trouble with ambulation.  she does have ataxia and uses a walker to ambulate.  there is no bradykinesia.  romberg is positive to the left.  cerebellar, finger-nose-finger is intact.  rapid alternating movements are intact.  upper airway examination, the patient has a friedman tongue position with 4 oropharyngeal crowding.  neck more than 16 to 17 inches, bmi elevated above 33.  head and neck circumference very high. impression:1.  cerebral palsy, worsening seizures.2.  hypertension.3.  dyslipidemia.4.  obstructive sleep apnea.5.  obesity. recommendations:1.  admission to the emu, drop her carbatrol 200 b.i.d., monitor for any epileptiform activity.  initial time of admission is 3 nights and 3 days.2.  outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  continue her other medications.3.  consult dr. x for hypertension, internal medicine management.4.  i will follow this patient per emu protocol.",neurology
+"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.",neurology
+"procedures:  esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy. reason for procedure:  child with abdominal pain and rectal bleeding.  rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations. consent:  history and physical examination was performed.  the procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  opportunity for questions was provided and informed consent was obtained. medication:  general anesthesia. instrument:  olympus gif-160. complications:  none. findings:  with the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  the esophageal mucosa and vascular pattern appeared normal.  the lower esophageal sphincter was located at 25 cm from the central incisors.  it appeared normal.  a z-line was identified within the lower esophageal sphincter.  the endoscope was advanced into the stomach, which distended with excess air.  rugal folds flattened completely.  gastric mucosa appeared normal throughout.  no hiatal hernia was noted.  pyloric valve appeared normal.  the endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  additional 2 biopsies were obtained for clo testing in the antrum.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated that part of procedure well.  the patient was turned and the scope was advanced with some difficulty to the terminal ileum.  the terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  the polyp was severed.  there was no bleeding at the stalk after removal of the polyp head.  the polyp head was removed by suction.  excess air was evacuated from the colon.  the patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  estimated blood loss approximately 5 ml. impression:  normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare. plan:  histologic evaluation and clo testing.  i will contact the parents next week with biopsy results and further management plans will be discussed at that time.",gastroenterology
+"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.",neurology
+"cc: episodic monocular blindness, os. hx: this 29 y/o rhf was in her usual healthy state until 2 months prior to her 3/11/96 presentation when she developed episodic arthralgias of her knees and ankles, bilaterally. on 3/3/96, she experienced sudden onset monocular blindness, os, lasting 5-10 minutes in duration. her vision "greyed out" from the periphery to center of her visual field, os; and during some episodes progressed to complete blindness (not even light perception). this resolved within a few minutes. she had multiple episodes of vision loss, os, every day until 3/7/96 when she was placed on heparin for suspected lica dissection. she saw a local ophthalmologist on 3/4/96 and was told she had a normal funduscopic exam. she experienced 0-1 spell of blindness (os) per day from 3/7/96 to 3/11/96. in addition, she complained of difficulty with memory since 3/7/96. she denied dysarthria, aphasia or confusion, but had occasional posterior neck and bioccipital-bitemporal headaches. she had no history of deep venous or arterial thrombosis. 3/4/96, esr=123. hct with and without contrast on 3/7/96 and 3/11/96, and carotid duplex scan were "unremarkable." rheumatoid factor=normal. 3-vessel cerebral angiogram (done locally) was reportedly "unremarkable." she was thought to have temporal arteritis and underwent temporal artery biopsy (which was unremarkable), she received prednisone 80 mg qd for 2 days prior to presentation. on admission she complained of a left temporal headache at the biopsy site, but no loss of vision or weakness she had been experiencing mild fevers and chills for several weeks prior to presentation. furthermore, she had developed cyanosis of the distal #3 toes on feet, and numbness and rash on the lateral aspect of her left foot. she developed a malar rash on her face 1-2 weeks prior to presentation. meds: depo-provera, prednisone 80mg qd, and heparin iv. pmh: 1)headaches for 3-4 years, 2)heart murmur, 3) cryosurgery of cervix, 4)tonsillectomy and adenoidectomy, 5) elective abortion. she had no history of spontaneous miscarriage and had used oral birth control pill for 10 years prior to presentation. fhx: migraine headaches on maternal side, including her mother. no family history of thrombosis. shx: works as a metal grinder and was engaged to be married. she denied any tobacco or illicit drug use. she consumed 1 alcoholic drink per month. exam: bp147/74, hr103, rr14, 37.5c. ms: a&o to person, place and time. speech was fluent without dysarthria. repetition, naming and comprehension were intact. 2/3 recall at 2 minutes. cn: unremarkable. motor: unremarkable. coord: unremarkable. sensory: decreased lt, pp, temp, along the lateral aspect of the left foot. gait: narrow-based and able to tt, hw and tw without difficulty. station: unremarkable. reflexes: 2/2 throughout. plantar responses were flexor, bilaterally. skin: cyanosis of the distal #3 toes on both feet. there was a reticular rash about the lateral aspect of her left foot. there were splinter-type hemorrhages under the fingernails of both hands. course:   esr=108 (elevated), hgb 11.3, hct 33%, wbc 10.0, plt 148k, mcv 92 (low) cr 1.3, bun 26, cxr and ekg were unremarkable. ptt 42 (elevated). pt normal. the rest of the gs and cbc were normal. dilute russell viper venom time was elevated at 27 and a 1:1 prothrombin time mix corrected to only 36. she was admitted to the neurology service. blood cultures were drawn and were negative. transthoracic and transesophageal echocardiography on 3/12/96 was unremarkable. her symptoms and elevated ptt suggested an ischemic syndrome involving anticardiolipin antibody and/or lupus anticoagulant. her signs of rash and cyanosis suggested sle. ana was positive at 1:640 (speckled), rf (negative), dsdna, 443 (elevated). serum cryoglobulins were positive at 1% (fractionation data lost). serum rpr was positive, but fta-abs was negative (thereby confirming a false-positive rpr). anticardiolipin antibodies igm and igg were positive at 56.1 and 56.3 respectively. myeloperoxidase antibody was negative, anca was negative and hepatitis screen unremarkable. the dermatology service felt the patient’s reticular foot rash was livedo reticularis. rheumatology felt the patient met criteria for sle. hematology felt the patient met criteria for anticardiolipin antibody and/or lupus anticoagulant syndrome. neurology felt the episodic blindness was secondary to thromboembolic events. serum iron studies revealed: fesat 6, serum fe 15, tibc 237, reticulocyte count 108.5. the patient was placed on feso4 225mg tid. she was continued on heparin iv, but despite this she continued to have occasional episodes of left monocular blindness or "gray outs" up to 5 times per day. she was seen by the neuro-ophthalmology service. the did not think she had evidence of vasculitis in her eye. they recommended treatment with asa 325mg bid. she was placed on this 3/15/96 and tapered off heparin. she continued to have 0-4 episodes of monocular blindness (os) for 5-10 seconds per episodes. she was discharged home. she returned 3/29/96 for episodic diplopia lasting 5-10 minutes per episode. the episodes began on 3/27/96. during the episodes her left eye deviated laterally while the right eye remained in primary gaze. she had no prior history of diplopia or strabismus. hgb 10.1, hct 30%, wbc 5.2, mcv 89 (low), plt 234k. esr 113mm/hr. pt 12, ptt 45 (high). hct normal. mri brain, 3/30/96, revealed a area of increased signal on t2 weighted images in the right frontal lobe white matter. this was felt to represent a thromboembolic event. she was place on heparin iv and treated with solu-medrol 125mg iv q12 hours. asa was discontinued. hematology, rheumatology and neurology agreed to place her on warfarin. she was placed on prednisone 60mg qd following the solu-medrol. she continued to have transient diplopia and mild vertigo despite inr’s of 2.0-2.2. asa 81mg qd was added to her regimen. in addition, rheumatology recommended plaquenil 200mg bid. the neurologic symptoms decreased gradually over the ensuing 3 days. warfarin was increased to achieve inr 2.5-3.5. she reported no residual symptoms or new neurologic events on her 5/3/96 neurology clinic follow-up visit. she continues to be event free on warfarin according to her hematology clinic notes up to 12/96.",neurology
+"indication:  coronary artery disease, severe aortic stenosis by echo. procedure performed:1.  left heart catheterization.2.  right heart catheterization.3.  selective coronary angiography. procedure:  the patient was explained about all the risks, benefits and alternatives to the procedure.  the patient agreed to proceed and informed consent was signed. both groins were prepped and draped in usual sterile fashion.  after local anesthesia with 2% lidocaine, 6-french sheath was inserted in the right femoral artery and 7-french sheath was inserted in the right femoral vein.  then right heart cath was performed using 7-french swan-ganz catheter.  catheter was placed in the pulmonary capillary wedge position.  pulmonary capillary wedge pressure, pa pressure was obtained, cardiac output was obtained, then rv, ra pressures were obtained.  the right heart catheter _______ pulled out.  then selective coronary angiography was performed using 6-french jl4 and 6-french 3drc catheter.  then attempt was made to cross the aortic valve with 6-french pigtail catheter, but it was unsuccessful.  after the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure.  the patient tolerated the procedure well.  there were no complications. hemodynamics:1.  cardiac output was 4.9 per liter per minute.  pulmonary capillary wedge pressure, mean was 7, pa pressure was 20/14, rv 26/5, ra mean pressure was 5.2.  coronary angiography, left main is calcified _______ dense complex.3.  lad proximal 70% calcified stenosis present and patent stent to the mid lad and diagonal 1 is a moderate-size vessel, has 70% stenosis.  left circumflex has diffuse luminal irregularities.  om1 has 70% stenosis, is a moderate-size vessel.  right coronary is dominant and has minimal luminal irregularities. summary:  three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure. recommendation:  aortic valve replacement with coronary artery bypass surgery.",cardiology
+"history:  the patient is a 61-year-old male patient.  i was asked to evaluate this patient because of the elevated blood urea and creatinine.  the patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post aicd.  the patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  the patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  the patient has been having increasing distention of the abdomen and frequent nosebleeds. past medical history:  as above. past surgical history:  the patient had a pacemaker placed. allergies:  nkda. review of systems:  showed no history of fever, no chills, no weight loss.  no history of sore throat.  no history of any ascites.  no history of nausea, vomiting, or diarrhea.  no black stools.  no history of any rash.  no back pain.  no leg pain.  no neuropsychiatric problems. family history:  history of hypertension, diabetes present. social history:  he is a nonsmoker, nonalcoholic, and not a drug user. physical examinationvital signs:  blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.heent:  the patient is atraumatic and normocephalic.  pupils are equal and reactive to light.  extraocular muscles are intact.neck:  supple.  no jvd and no thyromegaly.heart:  s1 and s2 heard.  no murmurs or extra sounds.abdomen:  distention of the abdomen present.extremities:  no pedal edema. laboratory:  his lab investigation showed wbc of 6.2, h&h is 11 and 34.  pt, ptt, and inr is normal.  urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc’s.  potassium is 5.3, bun of 39, and creatinine of 1.9.  liver function test, alt was 12, ast 15, albumin 3, tsh of 4.8, and t3 of 1.33. impression and plan:  the patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  the patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  we will do urine for cytology.  we will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, tibc, and serum ferritin levels.  we will send a psa level and if needed may be a urology consult.",nephrology
+"name of procedure1.  selective coronary angiography.2.  placement of overlapping 3.0 x 18 and 3.0 x 8 mm xience stents in the proximal right coronary artery.3.  abdominal aortography. indications:  the patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  thallium scan has been negative.  he is undergoing angiography to determine if his symptoms are due to coronary artery disease. narrative:  the right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  constant sedation was obtained using versed 1 mg and fentanyl 50 mcg.  received additional versed and fentanyl during the procedure.  please refer to the nurses’ notes for dosages and timing. the right femoral artery was entered and a 4-french sheath was placed.  advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  via the right judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  the right judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  this revealed a very high-grade lesion at the proximal right coronary artery.  this catheter was exchanged for a left #4 judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed. the patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  a 6-french sheath and a right judkins guide was placed.  the patient was started on bivalarudin.  a bmw wire was easily placed across the lesion and into the distal right coronary artery.  a 3.0 x 15 mm voyager balloon was placed and deployed at 10 atmospheres.  the intermediate result was improved with timi-3 flow to the terminus of the vessel.  following this, a 3.0 x 18 mm xience stent was placed across the lesion and deployed at 17 atmospheres.  this revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  this was stented with a 3.0 x 8 mm xience stent deployed again at 17 atmospheres.  final angiograms revealed excellent result with timi-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  the guiding catheter was withdrawn over wire and a pigtail was placed.  this was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  the catheter was removed.  the bivalarudin was stopped at the termination of procedure.  a small injection of contrast given through arterial sheath and angio-seal was placed without incident. it should also be noted that an 8-french sheath was placed in the right femoral vein.  this was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea. total contrast media, 205 ml, total fluoroscopy time was 7.5 minutes, x-ray dose, 2666 milligray. hemodynamics:  rhythm was sinus throughout the procedure.  aortic pressure was 170/81 mmhg. the right coronary artery is a dominant vessel.  this vessel gives rise to conus branch and two small rv free wall branches and pda and a small left ventricular branch.  it should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  in the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  after intervention, there is timi-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  there was approximately 10% residual stenosis at the worst part of the previous stenosis. the left main is without disease and trifurcates into a moderate-sized ramus intermedius, the lad and the circumflex.  the ramus intermedius is free of disease.  the lad terminates at the lv apex and has elongated area of mild stenosis at its mid segment.  this measures 25% to 30% at its worst point.  the circumflex is a large caliber vessel.  there is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the av groove. the aortogram demonstrates eccentric aneurysm formation.  this may represent a small retrograde dissection as well.  there was some dye hang up in the wall. impression1.  successful stenting of subtotal stenosis of the proximal coronary artery.2.  non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.3.  left to right collateral filling noted prior to coronary intervention.4.  small area of eccentric aneurysm formation in the abdominal aorta.",cardiology
+"the patient was taken to the gi lab and placed in the left lateral supine position.  continuous pulse oximetry and blood pressure monitoring were in place during the procedure.  after informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  the scope was advanced down the esophagus and into the body of the stomach.  the scope was further advanced to the pylorus and into the duodenum.  the duodenum was visualized well into its second portion and was free of stricture, neoplasm, or ulceration.  retroflexion view of the fundus was normal without evidence of abnormality.  the scope was then slowly removed.  the patient tolerated the procedure well.",gastroenterology
+"history:  smoking history 50-pack years of smoking. indication:  dyspnea. procedure:  fvc was 59%.  fev1 was 45%.  fev1/fvc ratio was 52%. the predicted was 67%.  fef 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  svc was 91%. inspiratory capacity was 70%.  residual volume was 225% of its predicted.  total lung capacity was 128%.   impression:1.  moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.2.  probably there is some restrictive element because of fibrosis.  the reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.3.  diffusion capacity was not measured.  the flow volume loop was consistent with the above.",pulmonary disease
+"neurological examination:  at present the patient is awake, alert and fully oriented.  there is no evidence of cognitive or language dysfunction.  cranial nerves:  visual fields are full.  funduscopic examination is normal.  extraocular movements full.  pupils equal, round,  react to light.  there is no evidence of nystagmus noted.  fifth nerve function is normal.  there is no facial asymmetry noted.  lower cranial nerves are normal.   manual motor testing reveals good tone and bulk throughout.  there is no evidence of pronator drift or decreased fine finger movements.  muscle strength is 5/5 throughout.  deep tendon reflexes are 2+ throughout with downgoing toes.  sensory examination is intact to all modalities including stereognosis, graphesthesia. testing of station and gait: the patient is able to walk toe-heel and tandem walk.  finger-to-nose and heel-to-shin moves are normal.  romberg sign negative.  i appreciate no carotid bruits or cardiac murmurs. noncontrast ct scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.",neurology
+"history of present illness:  the patient is a 78-year-old woman here because of recently discovered microscopic hematuria.  history of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation.  the patient has no new joint pains; however, she does have a history of chronic degenerative joint disease.  she does not use nonsteroidal agents.  she has had no gross hematuria and she has had no hemoptysis. review of systems:  no chest pain or shortness of breath, no problem with revision.  the patient has had decreased hearing for many years.  she has no abdominal pain or nausea or vomiting.  she has no anemia.  she has noticed no swelling.  she has no history of seizures. past medical history:  significant for hypertension and hyperlipidemia.  there is no history of heart attack or stroke.  she has had bilateral simple mastectomies done 35 years ago.  she has also had one-third of her lung removed for carcinoma (probably an adeno ca related to a pneumonia.)  she also had hysterectomy in the past. social history:  she is a widow.  she does not smoke. medications:1.  dyazide one a day.2.  pravachol 80 mg a day in the evening.3.  vitamin e once a day.4.  one baby aspirin per day. family history:  unremarkable. physical examination:  she looks younger than her stated age of 78 years.  she was hard of hearing, but could read my lips.  respirations were 16.  she was afebrile.  pulse was about 90 and regular.  her gait was normal.  blood pressure is 140/70 in her left arm seated.  heent:  she had arcus cornealis.  the pupils were equal.  the sclerae were not icteric.  the conjunctivae were pink.  neck:  the thyroid is not palpated.  no nodes were palpated in the neck.  chest:  clear to auscultation.  she had no sacral edema.  cardiac:  regular, but she was tachycardic at the rate of about 90.  she had no diastolic murmur.  abdomen:  soft, and nontender.  i did not palpate the liver.  extremities:  she had no appreciable edema.  she had no digital clubbing.  she had no cyanosis.  she had changes of the degenerative joint disease in her fingers.  she had good pedal pulses.  she had no twitching or myoclonic jerks. laboratory data:  the urine, i saw 1-2 red cells per high power fields.  she had no protein.  she did have many squamous cells.  the patient has creatinine of 1 mg percent and no proteinuria.  it seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine. plan:  to obtain a routine sonogram.  i would also repeat a routine urinalysis to check for blood again.  i have ordered a c3 and c4 and if the repeat urine shows red cells, i will recommend a cystoscopy with a retrograde pyelogram.",nephrology
+"chief complaint: stomach pain for 2 weeks. history of present illness: the patient is a 45yo mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. the pain was initially crampy and burning in character and was relieved with food intake. he also reports that it initially was associated with a sour taste in his mouth. he went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. in fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. it is relieved with standing and ambulation and exacerbated when lying in a supine position. he reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. he does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. he reports a 2 wk history of subjective fever and diaphoresis. he denies any diarrhea, constipation, dysuria, melena, or hematochezia. his last bowel movement was during the morning of admission and was normal. he denies any travel in the last 9 years and sick contacts. past medical history: right inguinal groin cyst removal 15 years ago. unknown etiology. no recurrence. past surgical history: left femoral neck fracture with prosthesis secondary to a fall 4 years ago. family history: mother with diabetes. no history of liver disease. no malignancies. social history: the patient was born in central mexico but moved to the united states 9 years ago. he is on disability due to his prior femoral fracture. he denies any tobacco or illicit drug use. he only drinks alcohol socially, no more than 1 drink every few weeks. he is married and has 3 healthy children. he denies any tattoos or risky sexual behavior. allergies: nkda. medications: tylenol prn (1-2 tabs every other day for the last 2 wks), cimetidine 400mg po qhs x 5 days. review of systems:  no headache, vision changes. no shortness of breath. no chest pain or palpitations. physical examination: vitals: t 100.9-102.7 bp 136/86 pulse 117 rr 12 98% sat on room air gen: well-developed, well-nourished, no apparent distress. heent: pupils equal, round and reactive to light. anicteric. oropharynx clear and moist. neck: supple. no lymphadenopathy or carotid bruits. no thyromegaly or masses. chest: clear to auscultation bilaterally. cv: tachycardic but regular rhythm, normal s1/s2, no murmurs/rubs/gallops. abd: soft, active bowel sounds. tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. no rebound tenderness. no hepatomegaly. no splenomegaly. rectal: stool was brown and guaiac negative. ext: no cyanosis/clubbing/edema. neurological: he was alert and oriented x3. cn ii-xii intact. normal 2+ dtrs. no focal neurological deficit. skin: no jaundice. no skin rashes or lesions. imaging data:ct abdomen with contrast ( 11/29/03 ):  there is a 6×6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. the rest of the liver parenchyma is homogeneous. the gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. the retroperitoneal vascular structures are within normal limits. there is no evidence of lymphadenopathy, free fluid or fluid collections. hospital course:  the patient was admitted to the hospital for further evaluation. a diagnostic procedure was performed.",gastroenterology
+"preoperative diagnoses:  malnutrition and dysphagia. postoperative diagnoses:  malnutrition and dysphagia with two antral polyps and large hiatal hernia. procedures:  esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. anesthesia:  iv sedation, 1% xylocaine locally. condition:  stable. operative note in detail:  after risk of operation was explained to this patient’s family, consent was obtained for surgery.  the patient was brought to the gi lab.  there, she was placed in partial left lateral decubitus position.  she was given iv sedation by anesthesia.  her abdomen was prepped with alcohol and then betadine.  flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  no lesions were noted in the duodenum.  there appeared to be a few polyps in the antral area, two in the antrum.  actually, one appeared to be almost covering the pylorus.  the scope was withdrawn back into the antrum.  on retroflexion, we could see a large hiatal hernia.  no other lesions were noted.  biopsy was taken of one of the polyps.  the scope was left in position.  anterior abdominal wall was prepped with betadine, 1% xylocaine was injected in the left epigastric area.  a small stab incision was made and a large bore angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient’s mouth.  tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  it was held in position with a dressing and a stent.  a connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  the patient tolerated the procedure well.  she was returned to the floor in stable condition.",gastroenterology
+"history:  coronary artery disease. technique and findings:  calcium scoring and coronary artery cta with cardiac function was performed on siemens dual-source ct scanner with postprocessing on vitrea workstation.  patient received oral metoprolol 100 milligrams.  100 ml ultravist 370 was utilized as the contrast agent.  0.4 milligrams of nitroglycerin was given. patient’s calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age.  there is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible. cardiac wall motion was within normal limits.  left ventricular ejection fraction calculated to be 82%.  end-diastolic volume 98 ml, end-systolic volume calculated to be 18 ml. there is normal coronary artery origins.  there is codominance between the right coronary artery and the circumflex artery.  there is mild to moderate stenosis of the proximal lad with mixed plaque.  mild stenosis mid lad with mixed plaque.  no stenosis.  distal lad with the distal vessel becoming diminutive in size.  right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque.  once again the distal vessel becomes diminutive in size.  circumflex shows mild stenosis due to focal calcified plaque proximally.  no stenosis is seen involving the mid or distal circumflex.  the distal circumflex also becomes diminutive in size.  the left main shows small amount of focal calcified plaque without stenosis.  myocardium, pericardium and wall motion was unremarkable as seen. impression:1.  atherosclerotic coronary artery disease with values as above.  there are areas of stenosis most pronounced in the lad with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.2.  consider cardiology consult and further evaluation if clinically indicated.3.  full report was sent to the pacs.  report will be mailed to dr. abc.",cardiology
+"reason for consultation:  coronary artery disease (cad), prior bypass surgery. history of present illness:  the patient is a 70-year-old gentleman who was admitted for management of fever.  the patient has history of elevated psa and bph.  he had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  from cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  no symptoms of chest pain or shortness of breath. his history from cardiac standpoint as mentioned below. coronary risk factors:  history of hypertension, history of diabetes mellitus, nonsmoker.  cholesterol elevated.  history of established coronary artery disease in the family and family history positive. family history:  positive for coronary artery disease. surgical history:  coronary artery bypass surgery and a prior angioplasty and prostate biopsies. medications:1.  metformin.2.  prilosec.3.  folic acid.4.  flomax.5.  metoprolol.6.  crestor.7.  claritin. allergies:  demerol, sulfa. personal history:  he is married, nonsmoker, does not consume alcohol, and no history of recreational drug use. past medical history:  significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated psa level, bph with questionable cancer.  symptoms of shortness of breath, fatigue, and tiredness. review of systems:constitutional:  no history of fever, rigors, or chills except for recent fever and rigors.heent:  no history of cataract or glaucoma.cardiovascular:  as above.respiratory:  shortness of breath.  no pneumonia or valley fever.gastrointestinal:  nausea and vomiting.  no hematemesis or melena.urological:  frequency, urgency.musculoskeletal:  no muscle weakness.skin:  none significant.neurological:  no tia or cva.  no seizure disorder.psychological:  no anxiety or depression.endocrine:  as above.hematological:  none significant. physical examination:vital signs:  pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.heent:  atraumatic, normocephalic.neck:  veins flat.  no significant carotid bruits.lungs:  air entry bilaterally fair.heart:  pmi displaced.  s1 and s2 regular.abdomen:  soft, nontender.  bowel sounds present.extremities:  no edema.  pulses are palpable.  no clubbing or cyanosis.cns:  benign. ekg:  normal sinus rhythm, incomplete right bundle-branch block. laboratory data:  h&h stable, bun and creatinine within normal limits. impression:1.  history of coronary artery disease, prior bypass surgery, angioplasty, significant shortness of breath.2.  fever with possible urinary tract infection versus prostatitis.3.  hypertension, hyperlipidemia, diabetes mellitus.4.  contemplated prostate surgery down the road. recommendation:1.  from cardiac standpoint, medical management including antibiotic for his fever.2.  we will consider cardiac workup in terms of to rule out ischemia and patency of the graft.  if he decides to go for surgery, i would like him to wait until the fever has subsided and is well under control.  discussed with the patient the plan of care, consent was obtained.  all the questions answered in detail.",cardiology
+"indications for procedure: this is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. cpk is already over 1000. there is st elevation in leads ii and avf, as well as a q wave. the chest pain is now gone, mild residual shortness of breath, no orthopnea. cardiac monitor shows resolution of st elevation lead iii. description of procedure: following sterile prep and drape of the right groin, installation of 1% xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-french sheath inserted. act approximately 165 seconds on heparin. borderline hypotension 250 ml fluid bolus given and nitroglycerin patch removed. selective left and right coronary injections performed using judkins coronary catheters with a 6-french pigtail catheter used to obtain left ventricular pressures and left ventriculography. left pullback pressure. sheath injection. hemostasis obtained with a 6-french angio-seal device. he tolerated the procedure well and was transported to the cardiac step-down unit in stable condition. hemodynamic data: left ventricular end diastolic pressure elevated post a-wave at 25 mm of mercury with no aortic valve systolic gradient on pullback. angiographic findings:i. left coronary artery: the left main coronary artery is unremarkable. the left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. the first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. the second diagonal branch is unremarkable, as are the tiny distal diagonal branches. the intermediate branch is a small, normal vessel. the ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small av sulcus circumflex branch. ii. right coronary artery: the right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. there are luminal irregularities, less than 25%, within the proximal to mid vessel. some contrast thinning is present in the distal rca just before the bifurcation into posterior descending and posterolateral branches. a 25%, smooth narrowing at the origin of the posterior descending branch. posterolateral branch is unremarkable and quite large, with secondary and tertiary branches. iii. left ventriculogram: the left ventricle is normal in size. ejection fraction estimated at 40 to 45%. no mitral regurgitation. severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion. discussion: recent inferior myocardial infarction with only minor contrast thinning distal rca remaining on coronary angiography with resolution of chest pain and st segment elevation. left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality. plan: medical treatment, including plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.",cardiology
+"procedures performed:  colonoscopy. indications:  renewed symptoms likely consistent with active flare of inflammatory bowel disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy. procedure:  informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  supplemental o2 given.  specifics discussed.  preprocedure physical exam performed.  stable vital signs.  lungs clear.  cardiac exam showed regular rhythm.  abdomen soft.  her past history, her past workup, her past visitation with me for inflammatory bowel disease, well responsive to sulfasalazine reviewed.  she currently has a flare and is not responding, therefore, likely may require steroid taper.  at the same token, her symptoms are mild.  she has rectal bleeding, essentially only some rusty stools.  there is not significant diarrhea, just some lower stools.  no significant pain.  therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed.  past history reviewed.  specifics of workup, need for followup, and similar discussed.  all questions answered. a normal digital rectal examination was performed.  the pcf-160 al was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice.  all mucosal aspects thoroughly inspected, including a retroflexed examination.  withdrawal time was greater than six minutes.  unfortunately, the terminal ileum could not be intubated despite multiple attempts. findings were those of a normal cecum, right colon, transverse colon, descending colon.  a small cecal polyp was noted, this was biopsy-removed, placed in bottle #1.  random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3.  there was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4.  there was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with crohn disease, given the relative sparing of the sigmoid colon and junk lesion.  retroflexed showed hemorrhoidal disease.  scope was then withdrawn, patient left in good condition.   impression:  active flare of inflammatory bowel disease, question of crohn disease. plan:  i will have the patient follow up with me, will follow up on histology, follow up on the polyps.  she will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job.  if not, she may be started on immune suppressive medication, such as azathioprine, or similar.  all of this has been reviewed with the patient.  all questions answered.",gastroenterology
+"this is a middle-aged female with memory loss. patient has history of breast carcinoma. evaluate for metastatic disease. findings:there is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent csf within the subarachnoid spaces. there is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. there is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. there is a cavum velum interpositum (normal variant). there is a linear area of t1 hypointensity becoming hyperintense on t2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space. normal basal ganglia and thalami. normal internal and external capsules. normal midbrain. there is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. there are areas of t2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. the area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. interval reassessment of this lesion is recommended. there is a remote lacunar infarction of the right cerebellar hemisphere. normal left cerebellar hemisphere and vermis. there is increased csf within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. there is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery. normal flow within the carotid arteries and circle of willis. normal calvarium, central skull base and temporal bones.  there is no demonstrated calvarium metastases. impression:severe generalized cerebral atrophy. extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. the area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. interval reassessment of this lesion is recommended. remote lacunar infarction in the right cerebellar hemisphere. linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or lacunar infarction. no demonstrated calvarial metastases.",neurology
+"reason for exam:  dynamic st-t changes with angina. procedure:1.  selective coronary angiography.2.  left heart catheterization with hemodynamics.3.  lv gram with power injection.4.  right femoral artery angiogram.5.  closure of the right femoral artery using 6-french angioseal. procedure explained to the patient, with risks and benefits.  the patient agreed and signed the consent form. the patient received a total of 2 mg of versed and 25 mcg of fentanyl for conscious sedation.  the patient was draped and dressed in the usual sterile fashion.  the right groin area infiltrated with lidocaine solution.  access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  over a j-wire, 6-french sheath was introduced using modified seldinger technique. over the j-wire, a jl4 catheter was passed over the aortic arch.  the wire was removed.  catheter was engaged into the left main.  multiple pictures with rao caudal, ap cranial, lao cranial, shallow rao, and lao caudal views were all obtained.  catheter disengaged and exchanged over j-wire into a jr4 catheter, the wire was removed.  catheter with counter-clock was rotating to the rca one shot with lao, position was obtained.  the cath disengaged and exchanged over j-wire into a pigtail catheter.  pigtail catheter across the aortic valve.  hemodynamics obtained.  lv gram with power injection of 36 ml of contrast was obtained. the lv gram assessed followed by pullback hemodynamics. the catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-french angioseal with no hematoma.  the patient tolerated the procedure well with no immediate postprocedure complication. hemodynamics:  the aortic pressure was 117/61 with a mean pressure of 83.  the left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmhg.  the pullback across the aortic valve reveals zero gradient. anatomy:  the left main showed minimal calcification as well as the proximal lad.  no stenosis in the left main seen, the left main bifurcates in to the lad and left circumflex. the lad was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was timi 3 flow in the lad.  the lad gave off two early diagonal branches.  the second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis. left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the pda.  the left circumflex was large and patent, 6.0 mm in diameter.  all three obtuse marginal branches appeared to be with no significant stenosis. the obtuse marginal branch, the third om3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  the pda was wide, patent, with no focal stenosis. the rca was a small nondominant system with no focal stenosis and supplying the rv marginal. lv gram showed that the lv ef is preserved with ef of 60%.  no mitral regurgitation identified. impression:1.  patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.2.  nondominant right, which is free of atheromatous plaque.3.  minimal plaque in the diagonal branch ii, and the obtusemarginal branch iii, with no focal stenosis.4.  normal left ventricular function.5.  evaluation for noncardiac chest pain would be recommended.",cardiology
+"operative procedure:  bronchoscopy brushings, washings and biopsies. history:  this is a 41-year-old woman admitted to medical center with a bilateral pulmonary infiltrate, immunocompromise. indications for the procedure:  bilateral infiltrates, immunocompromised host, and pneumonia. prior to procedure, the patient was intubated with 8-french et tube orally by anesthesia due to her profound hypoxemia and respiratory distress. description of procedure:  under mac and fluoroscopy, fiberoptic bronchoscope was passed through the et tube. et tube was visualized approximately 2 cm above the carina.  fiberoptic bronchoscope subsequently was passed through the right lower lobe area and transbronchial biopsies under fluoroscopy were done from the right lower lobe x3 as well as the brushings were obtained and the washings.  the patient tolerated the procedure well.  postprocedure, the patient is to be placed on a ventilator as well as postprocedure chest x-ray pending.  specimens are sent for immunocompromise panel including pcp stains. postprocedure diagnosis:  pneumonia, infiltrates.",pulmonary disease
+"history of present illness:  a 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  he had a ct scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  there was also a question of liver metastases at that time. operation performed:  fiberoptic bronchoscopy with endobronchial biopsies. the bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  the tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  approximately 15 biopsies were taken of the tumor.attention was then directed at the left upper lobe and lingula.  epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  approximately eight biopsies were taken of the left upper lobe.",pulmonary disease