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DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant.",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following: | {
"text": "DIAGNOSIS: , Ankle sprain, left ankle.,HISTORY: , The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month.,PAST MEDICAL HISTORY: , Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is \"dormant.\",MEDICATIONS:,1. Hydrochlorothiazide.,2. Lisinopril.,3. Percocet.,The patient states that the Percocet helps to take the edge of her pain, but does not completely eliminate it.,SUBJECTIVE: , The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.,FUNCTIONAL ACTIVITIES/HOBBIES: , Currently limited including basic household chores and activities, this does increases her pain. The patient states she also recently joined Weight Watchers and was involved in a walking routine and is currently unable to participate in this activity.,WORK STATUS: , The patient is currently on medical leave as a paraprofessional. The patient states that she works as a teacher's aide in the school system and is required to complete extensive walking and standing activities. The patient states that she is primarily on her feet while at work and rarely has a sitting break for extensive period of time. The patient's goal is to be able to stand and walk without pain.,SOCIAL HISTORY: ,The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine.,OBJECTIVE: , Upon observation, the patient is a very obese female who is ambulating with significant antalgic gait pattern and altered normal gait due to the pain as well as the walking boot. Upon inspection of the left ankle, it appears to have swelling, unsure if this swelling is secondary to injury or water retention as the patient states she has significant water retention. When compared to right ankle edema, it is approximately equal. There is no evidence of discoloration or temperature. The patient states that she had no bruising at the time of injury.,Active range of motion of left ankle is as follows: Dorsiflexion is 6 degrees past neutral and plantar flexion is 54 degrees, eversion 20 degrees, and inversion is 30 degrees. Left ankle dorsiflexion lacks 10 degrees from neutral and plantar flexion is 36 degrees, this motion is very painful. The patient was tearful during this activity. Eversion is 3 degrees and inversion is 25 degrees. The patient states this movement was difficult, but not painful. Strength testing of the right lower extremity is grossly 4+-5/5 and left ankle is 2/5 as the patient is unable to obtain full range of motion.,PALPATION: , The patient is very tender to palpation primarily along the lateral malleolus of the left ankle.,JOINT PLAY: , Unable to be assessed secondary to the patient's extreme tenderness and guarding of the ankle joint.,SPECIAL TESTS:, A 6-minute walk test. The patient was able to ambulate approximately 600 feet while wearing her walking boot prior to her pain significantly increasing in the ankle and requiring the test to be stopped.,ASSESSMENT: ,The patient would benefit from skilled physical therapy intervention as a trial of treatment in order to address the following problem list:,1. Increased pain.,2. Decreased range of motion.,3. Decreased strength.,4. Decreased ability to complete work task and functional activities in the home.,5. Decreased gait pattern.,SHORT-TERM GOALS TO BE COMPLETED IN 3 WEEKS:,1. The patient will demonstrate independence with home exercise program.,2. The patient will ambulate without her boot for 48 hours in order to decrease reliance upon the boot for ankle stabilization.,3. The patient will achieve left ankle dorsiflexion to neutral and plantar flexion to 45 degrees without significant increase in pain.,4. The patient will demonstrate 3/5 strength of the left ankle.,5. The patient will tolerate the completion of the 6-minute walk test without the use of a boot with minimal increase in pain.,LONG-TERM GOALS TO BE COMPLETED IN 6 WEEKS:,1. The patient will report 0/10 pain in the 48-hour period without the use of medication and without wearing her boot.,2. The patient will return to go through the work without the use of the walking boot with report of minimal increase in pain and discomfort.,PROGNOSIS:, Fair for above-stated goals with full compliance to home exercise program and therapy treatment as well as the patient motivation.,PLAN: , The patient to be seen three times a week for 6 weeks for the following:"
} | [
{
"label": " Physical Medicine - Rehab",
"score": 1
}
] | Argilla | null | null | false | null | c2b9743d-7f52-4926-a56b-d83b67476b90 | null | Default | 2022-12-07T09:35:43.607493 | {
"text_length": 5185
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PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. The patient has requested surgical intervention at this time.,PROCEDURE: ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room. The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle. Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg. The foot was then brought back down to the table using bandage scissors. The stockinette was reflected and the right foot was exposed. Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. Further dissection was then performed in the medial direction in the area of the soft tissue mass. The intermediate dorsal cutaneous nerve was identified and gently retracted laterally. Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. Using careful dissection, adipose tissue in this area was removed and saved for pathology. Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. No deficits were noted. No abnormal appearing tissue was present within the surgical site. Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed. Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban. The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot. The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe. The patient was then given postoperative instructions to include ice and elevation to her right foot. The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up. The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days. The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit. | {
"text": "PREOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,POSTOPERATIVE DIAGNOSIS: , Soft tissue mass, right foot.,PROCEDURE PERFORMED: , Excision of soft tissue mass, right foot.,HISTORY: ,The patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. The patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. The patient has requested surgical intervention at this time.,PROCEDURE: ,After an IV was instituted by the Department of Anesthesia, the patient was escorted from the preoperative holding area to the operating room. The patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. Using copious amounts of Webril, a pneumatic ankle tourniquet was applied to her right ankle. Using a Skin Skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. After adequate amount of anesthesia was provided by the Department of Anesthesia, a local ankle block was given using 10 cc of 4.5 mL of 1% lidocaine plain, 4.5 mL of 0.5% Marcaine plain and 1.0 mL of Solu-Medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. Following this, the ankle was elevated and Esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmHg. The foot was then brought back down to the table using bandage scissors. The stockinette was reflected and the right foot was exposed. Using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. Then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. Following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. Further dissection was then performed in the medial direction in the area of the soft tissue mass. The intermediate dorsal cutaneous nerve was identified and gently retracted laterally. Large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. Using careful dissection, adipose tissue in this area was removed and saved for pathology. Following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. Using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. There was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. Following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. The wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. The tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. No deficits were noted. No abnormal appearing tissue was present within the surgical site. Following this, the skin edges were reapproximated using #4-0 Vicryl deep closure of the subcutaneous layer was performed. Then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. The patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. Following this, the wound was dressed using Xeroform gauze and 4x4s and was dressed using two ABD pads, dorsal and plantar for compression and using Kling, Kerlix and Coban. The patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmHg and immediate hyperemia was noted to digits one through five of the right foot. The patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. The patient was then escorted to the Postanesthesia Care Unit where she was placed in a surgical shoe. The patient was then given postoperative instructions to include ice and elevation to her right foot. The patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. The patient will follow up with Dr. X in his office on Tuesday, 08/26/03 for further follow up. The patient was given prescription for Vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for Keflex #20 500 mg tablets to be taken b.i.d. x10 days. The patient was given a number for the Emergency Room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. The patient had no further questions and recovered without any complications in the Postanesthesia Care Unit."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c2bd9cef-e25d-4c2b-a9ae-1feda5f33ee0 | null | Default | 2022-12-07T09:33:33.574531 | {
"text_length": 5543
} |
PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications. | {
"text": "PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS: ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME: ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient. The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position. All bony prominences were well padded at this time. At this time, Department of Anesthesia administered general anesthetic to the patient. The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left. The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time. The right lower extremity was sterilely prepped and draped in the usual sterile fashion. The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg. The patient was a consideration for a unicompartmental knee replacement. So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella. A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon. Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel. Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement. At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion. Total incision now measured approximately 25 cm. Retractors were placed. Next, attention was directed to establishing medial and lateral flaps of the proximal tibia. Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia. At this time, the patella was then everted. The knee was flexed up to 90 degrees. Next, using the large drill bit, the femoral canal was then opened in appropriate position. The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline. The guide was then removed. The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation. Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed. Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut. Upon checking, it was noted to be flat with no oscillations. The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus. It was secured in place using nails. The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position. Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws. Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut. A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well. The distal finishing guide was then removed and osteotome was then used to remove all resected bone. The oscillating saw was then used to complete the femoral notch cut. Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely. There was no posterior osteophytes noted and no fragments to the posterior aspect. Next, attention was directed towards the tibia. The external tibial guide was reflected. This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position. The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia. Next, collateral ligament retractors were placed as well as McGill retractors for the PCL. Oscillating saw was then used to make the proximal tibial cut. Osteotome was used to remove this excess resected bone. The laminar spreader was then used to check the flexion and extension. The gaps appeared to be equal. The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray. The knee was taken through range of motion and had very good flexion as well as full extension. There appeared to be good varus and valgus stability as well. Next, attention was directed towards the patella. There noted to be a sufficient ware and it was selected to replace the patella. It was sized with caliper, pre-cut and noted to be 26 mm depth. The sizing guide was then used and a size 51 resection guide selected. A 51 mm reamer was then placed and sufficient amount of patella was then removed. The calcar was then used to check again and there was noted to be 15 mm remaining. The 38 mm patella guide was then placed on the patella. It was noted to be in proper size and the three drill holes for the pegs were used. A trial component was then placed. The knee was taken through range of motion. There was noted to be some subluxation lateral to the patellar component and a lateral release was performed. After this, the component appeared to be tracking very well. There remained a good range of motion in the knee and extension as well as flexion. At this time, an AP x-ray of the knee was taken with the trial components in place. Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning. The knee was then copiously irrigated and dried. The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled. The knee again was copiously irrigated and suction dried. The final components were then selected again consisting of size F femoral components. A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella. Polymethyl methacrylate was then prepared at this time. The proximal tibia was dried and the cement was then pressed into place. The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning. Next, the proximal femur was cleaned and dried. Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components. This was then impacted in place as well. At this time, all excess cement was removed from both the tibial and femoral components. A size 12 mm trial tibial articular surface was then put in place. The knee was reduced and held in loading position throughout the remaining drying position of the cement. Next, the resected patella was cleaned and dried. The cement was placed on the patella as well as the backside of the patellar component. The component was then put in proper positioning and held in place with a clamp. All excess polymethyl methacrylate was removed from this area as well. This was held until the cement had hardened sufficiently. Next, the knee was examined. All excess cement was then removed. The knee was taken through range of motion with sufficient range of motion as well as stability. The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position. Again range of motion was noted to be sufficient. The knee was copiously irrigated and suction dried once again. A drain was then placed within the knee. The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl. The knee was again copiously irrigated and dried. The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin. The ConstaVac was then _______ to the drain. Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh. Department of Anesthesia then reversed the anesthetic. The patient was transferred back to the hospital gurney to Postanesthesia Care Unit. The patient tolerated the procedure well and there were no complications."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c2d0a640-d7d3-46f8-9915-89919eebb189 | null | Default | 2022-12-07T09:36:16.714061 | {
"text_length": 9990
} |
HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future. | {
"text": "HISTORY:, The patient is a 46-year-old right-handed gentleman with a past medical history of a left L5-S1 lumbar microdiskectomy in 1998 with complete resolution of left leg symptoms, who now presents with a four-month history of gradual onset of right-sided low back pain with pain radiating down into his buttock and posterior aspect of his right leg into the ankle. Symptoms are worsened by any activity and relieved by rest. He also feels that when the pain is very severe, he has some subtle right leg weakness. No left leg symptoms. No bowel or bladder changes.,On brief examination, full strength in both lower extremities. No sensory abnormalities. Deep tendon reflexes are 2+ and symmetric at the patellas and absent at both ankles. Positive straight leg raising on the right.,MRI of the lumbosacral spine was personally reviewed and reveals a right paracentral disc at L5-S1 encroaching upon the right exiting S1 nerve root.,NERVE CONDUCTION STUDIES:, Motor and sensory distal latencies, evoked response amplitudes, and conduction velocities are normal in the lower extremities. The right common peroneal F-wave is minimally prolonged. The right tibial H reflex is absent.,NEEDLE EMG:, Needle EMG was performed on the right leg, left gastrocnemius medialis muscle, and right lumbosacral paraspinal muscles using a disposable concentric needle. It revealed spontaneous activity in the right gastrocnemius medialis, gluteus maximus, and lower lumbosacral paraspinal muscles. There was evidence of chronic denervation in right gastrocnemius medialis and gluteus maximus muscles.,IMPRESSION: , This electrical study is abnormal. It reveals an acute right S1 radiculopathy. There is no evidence for peripheral neuropathy or left or right L5 radiculopathy.,Results were discussed with the patient and he is scheduled to follow up with Dr. X in the near future."
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c2dcda1b-fd1d-431e-a36f-ff2d2caf9b2e | null | Default | 2022-12-07T09:35:22.251819 | {
"text_length": 1880
} |
EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis. | {
"text": "EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis."
} | [
{
"label": " Gastroenterology",
"score": 1
}
] | Argilla | null | null | false | null | c2dd8612-2d30-4d66-a183-b4d0a1de78d9 | null | Default | 2022-12-07T09:38:38.237775 | {
"text_length": 1920
} |
ADMISSION DIAGNOSES:,1. Menorrhagia.,2. Uterus enlargement.,3. Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period. She also had symptoms of back pain, dysmenorrhea, and dysuria. The symptoms had been worsening over time. The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:, The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE: ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy. The procedure preceded as planned without complication. Uterus was sent for pathologic analysis. The patient was monitored in the hospital, 2 days postoperatively. She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION: ,The patient was discharged to home in stable condition. She was instructed to follow up in the office postoperatively. | {
"text": "ADMISSION DIAGNOSES:,1. Menorrhagia.,2. Uterus enlargement.,3. Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period. She also had symptoms of back pain, dysmenorrhea, and dysuria. The symptoms had been worsening over time. The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:, The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE: ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy. The procedure preceded as planned without complication. Uterus was sent for pathologic analysis. The patient was monitored in the hospital, 2 days postoperatively. She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION: ,The patient was discharged to home in stable condition. She was instructed to follow up in the office postoperatively."
} | [
{
"label": " Obstetrics / Gynecology",
"score": 1
}
] | Argilla | null | null | false | null | c2e1d366-fd89-4e47-b55e-75c7bc5a530d | null | Default | 2022-12-07T09:36:57.221219 | {
"text_length": 1389
} |
PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1. Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2. Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position. Dressing was removed from the left eye, which revealed the defect as noted above. After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid. The patient was prepped and draped in the usual ophthalmic fashion. Protective scleral shell was placed in the left eye. A 4-0 silk traction sutures placed through the upper eyelid margin. The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound. The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid. Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border. The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture. The protective scleral shell was removed from the eye. The medial aspect of the eyelid was advanced temporally. The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures. The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture. The upper eyelid wound was present. It was advanced to the advanced tarsoconjunctival pedicle temporally. The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures. Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures. Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture. Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim. The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure. Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure. The patient tolerated the procedure well and left the operating room in excellent condition. There were no apparent complications. | {
"text": "PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1. Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2. Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position. Dressing was removed from the left eye, which revealed the defect as noted above. After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid. The patient was prepped and draped in the usual ophthalmic fashion. Protective scleral shell was placed in the left eye. A 4-0 silk traction sutures placed through the upper eyelid margin. The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound. The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid. Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border. The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture. The protective scleral shell was removed from the eye. The medial aspect of the eyelid was advanced temporally. The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures. The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture. The upper eyelid wound was present. It was advanced to the advanced tarsoconjunctival pedicle temporally. The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures. Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures. Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture. Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim. The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure. Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure. The patient tolerated the procedure well and left the operating room in excellent condition. There were no apparent complications."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c2e517be-cc34-4422-bcb4-d1e6ddf7ac75 | null | Default | 2022-12-07T09:33:15.517445 | {
"text_length": 3554
} |
PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE: , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications. | {
"text": "PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE: , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact. The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications."
} | [
{
"label": " Gastroenterology",
"score": 1
}
] | Argilla | null | null | false | null | c2e96186-7ebd-4e07-8672-97fc5ce50772 | null | Default | 2022-12-07T09:38:31.942724 | {
"text_length": 2553
} |
HISTORY OF PRESENT ILLNESS:, This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney. His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable. He denies any chest pain or tightness in his chest. He denies any shortness of breath, nausea, or vomiting. He denies any change to his appetite. He denies any fevers, chills, dysuria, or hematuria. He does report his blood pressure being checked at the senior center and reporting that it is improved. The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:, | {
"text": "HISTORY OF PRESENT ILLNESS:, This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney. His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable. He denies any chest pain or tightness in his chest. He denies any shortness of breath, nausea, or vomiting. He denies any change to his appetite. He denies any fevers, chills, dysuria, or hematuria. He does report his blood pressure being checked at the senior center and reporting that it is improved. The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,"
} | [
{
"label": " Office Notes",
"score": 1
}
] | Argilla | null | null | false | null | c2eba970-cf54-44c6-abb2-69393ba0f133 | null | Default | 2022-12-07T09:36:44.937111 | {
"text_length": 654
} |
PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct. | {
"text": "PREOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:, Cervical spondylotic myelopathy with cord compression and cervical spondylosis. In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion. Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4. Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5. It appeared that the C5-C6 disk area had fused spontaneously. We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. This was then removed with 2-mm Kerrison rongeur. After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. We did foraminotomies at C3-C4 as well as C4-C5 as well. After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place. The distraction was removed and the grafts were now within. We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws. X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia. Meticulous hemostasis was obtained. The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue. Steri-Strips were used for skin closure. Blood loss less than about 200 mL. No complications of the surgery. Needle counts, sponge count, and cottonoid count was correct."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c2f71818-e621-41c1-b97d-1dbd57618400 | null | Default | 2022-12-07T09:36:31.577493 | {
"text_length": 2954
} |
PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke. She denies any history of cancer. She does have a history of hepatitis which I will need to further investigate. She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal. She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:, She is a single mother of one adopted child.,FAMILY HISTORY: ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family. Her mother is alive. Her father is deceased from alcohol. She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female. She does not appear to have any significant residual deficits from her stroke. There may be slight left arm weakness.,ASSESSMENT/PLAN:, We will have her undergo routine nutritional and psychosocial assessment. I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss. She is otherwise at increased risk for future complications given her history, and weight loss will be a good option. We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company. | {
"text": "PAST MEDICAL HISTORY: , Her medical conditions driving her toward surgery include hypercholesterolemia, hypertension, varicose veins, prior history of stroke. She denies any history of cancer. She does have a history of hepatitis which I will need to further investigate. She complains of multiple joint pains, and heavy snoring.,PAST SURGICAL HISTORY: , Includes hysterectomy in 1995 for fibroids and varicose vein removal. She had one ovary removed at the time of the hysterectomy as well.,SOCIAL HISTORY:, She is a single mother of one adopted child.,FAMILY HISTORY: ,There is a strong family history of heart disease and hypertension, as well as diabetes on both sides of her family. Her mother is alive. Her father is deceased from alcohol. She has five siblings.,MEDICATIONS: , As you know she takes the following medications for her diabetes, insulin 70 units/6 units times four years, aspirin 81 mg a day, Actos 15 mg, Crestor 10 mg and CellCept 500 mg two times a day.,ALLERGIES: , She has no known drug allergies.,PHYSICAL EXAM: , She is a 54-year-old obese female. She does not appear to have any significant residual deficits from her stroke. There may be slight left arm weakness.,ASSESSMENT/PLAN:, We will have her undergo routine nutritional and psychosocial assessment. I suspect that we can significantly improve the situation with her insulin and oral hypoglycemia, as well as hypertension, with significant weight loss. She is otherwise at increased risk for future complications given her history, and weight loss will be a good option. We will see her back in the office once she completes her preliminary workup and submit her for approval to the insurance company."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c3037c63-ab6a-41f3-9bb5-a814909741af | null | Default | 2022-12-07T09:40:15.904171 | {
"text_length": 1702
} |
CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:, Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type,COMMENT:, Right upper lobe, lobectomy.,Tumor type: Bronchioloalveolar carcinoma, mucinous type.,Histologic grade: Well differentiated.,Tumor size (greatest diameter): 3.6 cm.,Blood/lymphatic vessel invasion: Absent.,Perineural invasion: Absent.,Bronchial margin: Negative.,Vascular margin: Negative.,Inked surgical margin: Negative.,Visceral pleura: Not involved.,In situ carcinoma: Absent.,Non-neoplastic lung: Emphysema.,Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.,P53 immunohistochemical stain is negative in the tumor. | {
"text": "CLINICAL HISTORY: ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:, Specimen is received fresh for frozen section, labeled with the patient's identification and \"Right upper lobe lung\". It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. There is no necrosis or hemorrhage evident. The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:, Right lung, upper lobe, lobectomy: Bronchioloalveolar carcinoma, mucinous type,COMMENT:, Right upper lobe, lobectomy.,Tumor type: Bronchioloalveolar carcinoma, mucinous type.,Histologic grade: Well differentiated.,Tumor size (greatest diameter): 3.6 cm.,Blood/lymphatic vessel invasion: Absent.,Perineural invasion: Absent.,Bronchial margin: Negative.,Vascular margin: Negative.,Inked surgical margin: Negative.,Visceral pleura: Not involved.,In situ carcinoma: Absent.,Non-neoplastic lung: Emphysema.,Hilar lymph nodes: Number of positive lymph nodes: 0; Total number of lymph nodes: 1.,P53 immunohistochemical stain is negative in the tumor."
} | [
{
"label": " Lab Medicine - Pathology",
"score": 1
}
] | Argilla | null | null | false | null | c32c3649-8457-4f5a-9789-33e76000e823 | null | Default | 2022-12-07T09:37:45.975109 | {
"text_length": 1459
} |
CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.,SOCIAL HISTORY: , The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS: | {
"text": "CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes.,SOCIAL HISTORY: , The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:"
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c33feab2-2063-4ada-9ce1-97d3d0ef8605 | null | Default | 2022-12-07T09:39:28.826266 | {
"text_length": 3503
} |
EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine. | {
"text": "EXAM: , MRI of lumbar spine without contrast.,HISTORY:, A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position. Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1: Central canal, neural foramina are patent.,L4-L5: Central canal, neural foramina are patent.,L3-L4: Central canal, neural foramen is patent.,L2-L3: Central canal, neural foramina are patent.,L1-L2: Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber. Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c34fdf9e-a303-4efd-8425-3433ca235be2 | null | Default | 2022-12-07T09:36:09.874904 | {
"text_length": 1123
} |
SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding and stooling pattern. No concerns with hearing or vision. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Allergies: None. Medications: Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:, Unchanged since last checkup.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:, Weight 24 pounds 1 ounce. Height 30 inches. Head circumference 46.5 cm. Temperature afebrile.,General: A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT: Atraumatic, normocephalic. Anterior fontanel is closed. Pupils equally round and reactive. Sclerae are clear. Red reflex present bilaterally. Extraocular muscles intact. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink. Good dentition. Drooling and chewing with teething behavior today. Neck is supple. No lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze. No crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No mass. No organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength. Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1. Well 1-year-old white female.,2. Anticipatory guidance. Reviewed growth, diet development and safety issues as well as immunizations. Will receive Pediarix and HIB today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available. Gave 1-year well child checkup handout to Mom and Dad.,3. Follow up for the 15-month well child check or as needed for acute care. | {
"text": "SUBJECTIVE:, The patient presents with Mom and Dad for her 1-year well child check. The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. Normal voiding and stooling pattern. No concerns with hearing or vision. Growth and development: Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development. See Denver II form in the chart.,PAST MEDICAL HISTORY:, Allergies: None. Medications: Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:, Unchanged since last checkup.,REVIEW OF SYSTEMS:, As per HPI; otherwise negative.,OBJECTIVE:, Weight 24 pounds 1 ounce. Height 30 inches. Head circumference 46.5 cm. Temperature afebrile.,General: A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT: Atraumatic, normocephalic. Anterior fontanel is closed. Pupils equally round and reactive. Sclerae are clear. Red reflex present bilaterally. Extraocular muscles intact. TMs are clear bilaterally. Oropharynx: Mucous membranes are moist and pink. Good dentition. Drooling and chewing with teething behavior today. Neck is supple. No lymphadenopathy.,Chest: Clear to auscultation bilaterally. No wheeze. No crackles. Good air exchange.,Cardiovascular: Regular rate and rhythm. No murmur. Good pulses bilaterally.,Abdomen: Soft, nontender. Nondistended. Positive bowel sounds. No mass. No organomegaly.,Genitourinary: Tanner I female genitalia. Femoral pulses equal bilaterally. No rash.,Extremities: Full range of motion. No cyanosis, clubbing or edema. Negative Ortolani and Barlow maneuver.,Back: Straight. No scoliosis.,Integument: Warm, dry and pink without lesions.,Neurological: Alert. Good muscle tone and strength. Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1. Well 1-year-old white female.,2. Anticipatory guidance. Reviewed growth, diet development and safety issues as well as immunizations. Will receive Pediarix and HIB today. Discussed risks and benefits as well as possible side effects and symptomatic treatment. Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available. Gave 1-year well child checkup handout to Mom and Dad.,3. Follow up for the 15-month well child check or as needed for acute care."
} | [
{
"label": " Pediatrics - Neonatal",
"score": 1
}
] | Argilla | null | null | false | null | c3555fee-2062-469f-8a58-3fd63477ca05 | null | Default | 2022-12-07T09:35:45.582637 | {
"text_length": 2663
} |
PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE: ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops. Topical anesthetic drops were applied to the eye just prior to entering the operating room. The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber. A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition. | {
"text": "PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE: ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops. Topical anesthetic drops were applied to the eye just prior to entering the operating room. The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade. Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber. A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c36316f7-a1df-463c-839f-9b508e9049fd | null | Default | 2022-12-07T09:33:22.309904 | {
"text_length": 2227
} |
SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed. | {
"text": "SUBJECTIVE:, Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable. ,OBJECTIVE:, Her blood pressure is 110/60. Other vitals are stable. HEENT: Unremarkable. Neck: Unremarkable. Lungs: Clear. Heart: Regular. Abdomen: Unchanged. Extremities: Unchanged. Neurologic: Unchanged. ,ASSESSMENT:, ,1. NIDDM with improved control. ,2. Hypertension. ,3. Coronary artery disease status post coronary artery bypass graft. ,4. Degenerative arthritis. ,5. Hyperlipidemia. ,6. Hyperuricemia. ,7. Renal azotemia. ,8. Anemia. ,9. Fibroglandular breasts. ,PLAN:, We will get follow-up labs today. We will continue with current medications and treatment. We will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately Month DD, YYYY. The patient is advised to proceed with previous recommendations. She is to follow-up with Ophthalmology and Podiatry for diabetic evaluation and to return for follow-up as directed."
} | [
{
"label": " General Medicine",
"score": 1
}
] | Argilla | null | null | false | null | c37be133-ed9c-44a7-bc7f-9eff49405aa1 | null | Default | 2022-12-07T09:38:07.538109 | {
"text_length": 1195
} |
SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:, Otherwise, reviewed. Very healthy.,CURRENT MEDICATIONS:, Claritin p.r.n.,ALLERGIES TO MEDICINES:, None.,FAMILY SOCIAL HISTORY:, Everyone else is healthy at home currently.,DIETARY:, He is on whole milk and does a variety of foods. Growth chart is reviewed with mother. Voids and stools well.,DEVELOPMENTAL:, He is in seventh grade and going out for cross-country and track. He is supposed to be wearing glasses, is not today. We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother. His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General: A well-developed, well-nourished male in no acute distress.,Dermatologic: Without rash or lesion.,HEENT: Head normocephalic and atraumatic. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes are present bilaterally. Optic discs are sharp with normal vasculature. Ears: Tympanic membranes are gray, translucent with normal light reflex. Nares are very congested. Turbinates swollen and boggy.,Neck: Supple without masses.,Chest: Clear to auscultation and percussion, easy respirations. No accessory muscle use.,Cardiovascular: Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back: Symmetric with no scoliosis or kyphosis noted. Normal flexibility. Femoral pulses 2+ and symmetric.,Abdomen: Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam: Normal Tanner III male. Testes descended bilaterally. No abnormal rash, discharge, or scars.,Extremities: Pink and warm. Moves all extremities well with normal function and strength in the arms and legs. Normal balance, station, and gait. Normal speech.,Neurologic: Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:, Healthy Tanner III male, developing normally.,PLAN:,1. Diet, growth, safety, drugs, violence, and social competence all discussed.,2. Immunizations reviewed.,3. We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4. Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n. | {
"text": "SUBJECTIVE:, This is a 12-year-old male who comes in for healthy checkups and sports physical. No major concerns today. He is little bit congested at times. He has been told he is allergic to grasses. They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports. He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:, Otherwise, reviewed. Very healthy.,CURRENT MEDICATIONS:, Claritin p.r.n.,ALLERGIES TO MEDICINES:, None.,FAMILY SOCIAL HISTORY:, Everyone else is healthy at home currently.,DIETARY:, He is on whole milk and does a variety of foods. Growth chart is reviewed with mother. Voids and stools well.,DEVELOPMENTAL:, He is in seventh grade and going out for cross-country and track. He is supposed to be wearing glasses, is not today. We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother. His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General: A well-developed, well-nourished male in no acute distress.,Dermatologic: Without rash or lesion.,HEENT: Head normocephalic and atraumatic. Eyes: Pupils equal, round and reactive to light. Extraocular movements intact. Red reflexes are present bilaterally. Optic discs are sharp with normal vasculature. Ears: Tympanic membranes are gray, translucent with normal light reflex. Nares are very congested. Turbinates swollen and boggy.,Neck: Supple without masses.,Chest: Clear to auscultation and percussion, easy respirations. No accessory muscle use.,Cardiovascular: Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back: Symmetric with no scoliosis or kyphosis noted. Normal flexibility. Femoral pulses 2+ and symmetric.,Abdomen: Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam: Normal Tanner III male. Testes descended bilaterally. No abnormal rash, discharge, or scars.,Extremities: Pink and warm. Moves all extremities well with normal function and strength in the arms and legs. Normal balance, station, and gait. Normal speech.,Neurologic: Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:, Healthy Tanner III male, developing normally.,PLAN:,1. Diet, growth, safety, drugs, violence, and social competence all discussed.,2. Immunizations reviewed.,3. We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4. Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n."
} | [
{
"label": " Pediatrics - Neonatal",
"score": 1
}
] | Argilla | null | null | false | null | c3846872-207a-428b-86de-b861da56b670 | null | Default | 2022-12-07T09:35:46.447307 | {
"text_length": 2715
} |
SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome. Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1. She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004. She was last seen on 04/08/2005 with recurrent pain in her low back on the right. Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today. She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint. She is also complaining of pain in both knees. She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly. She has not had any x-rays for quite some time. She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms. She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:, Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 5 inches. Weight is 183 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.,Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.,Spine: Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint. She has no other major tenderness. Spinal movements are limited but functional.,Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2. Improved, spinal right L3-S1 radiofrequency ablation.,3. Right sacroiliac joint sprain/strain, symptomatic.,4. Left lumbar facet joint syndrome, stable.,6. Right thoracic facet joint syndrome, stable.,7. Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8. Degenerative disc disease of both knees, symptomatic.,9. Pes anserinus bursitis, bilaterally symptomatic.,10. Chronic pain syndrome.,RECOMMENDATIONS:, Dr. XYZ and I discussed with the patient her pathology. She has some symptoms in her low back on the right side at the sacroiliac joint. Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy. She is also having pain in both knees. We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally. I explained the rationale for each of these injections, possible complications and she wishes to proceed. In the interim, she can continue on Lortab and Celebrex. We will plan for the follow up following these interventions, sooner if needed. She voiced understanding and agreement. Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings. | {
"text": "SUBJECTIVE:, The patient comes back to see me today. She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome. Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1. She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004. She was last seen on 04/08/2005 with recurrent pain in her low back on the right. Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today. She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint. She is also complaining of pain in both knees. She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly. She has not had any x-rays for quite some time. She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms. She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:, Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General: Reveals a pleasant Caucasian female.,Vital Signs: Height is 5 feet 5 inches. Weight is 183 pounds. She is afebrile.,HEENT: Benign.,Neck: Shows functional range of movements with a negative Spurling's.,Musculoskeletal: Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa. Straight leg raises are negative bilaterally. Posterior tibials are palpable bilaterally.,Skin and Lymphatics: Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers. No significant lymphadenopathy noted.,Spine: Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint. She has no other major tenderness. Spinal movements are limited but functional.,Neurological: She is alert and oriented with appropriate mood and affect. She has normal tone and coordination. Reflexes are 2+ and symmetrical. Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:, Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1. Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2. Improved, spinal right L3-S1 radiofrequency ablation.,3. Right sacroiliac joint sprain/strain, symptomatic.,4. Left lumbar facet joint syndrome, stable.,6. Right thoracic facet joint syndrome, stable.,7. Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8. Degenerative disc disease of both knees, symptomatic.,9. Pes anserinus bursitis, bilaterally symptomatic.,10. Chronic pain syndrome.,RECOMMENDATIONS:, Dr. XYZ and I discussed with the patient her pathology. She has some symptoms in her low back on the right side at the sacroiliac joint. Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy. She is also having pain in both knees. We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally. I explained the rationale for each of these injections, possible complications and she wishes to proceed. In the interim, she can continue on Lortab and Celebrex. We will plan for the follow up following these interventions, sooner if needed. She voiced understanding and agreement. Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c38cdfdf-60cf-4b52-8e94-45447690c7c9 | null | Default | 2022-12-07T09:36:06.245847 | {
"text_length": 4213
} |
CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:, T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation. | {
"text": "CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:, T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation."
} | [
{
"label": " Neurology",
"score": 1
}
] | Argilla | null | null | false | null | c3915f8a-d503-47b4-9c7f-4b14e7d48a49 | null | Default | 2022-12-07T09:37:18.492543 | {
"text_length": 3552
} |
PREOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,PROCEDURES:,1. Cystoscopy.,2. Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer. His history dates back to 2003 when he had a non-muscle invasive bladder cancer. He had multiple cystoscopies and followups since that time with no evidence of recurrence. However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ. Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities. I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites. We elected to allow his bladder to recover before starting the BCG. We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter. I repeated a cystoscopy in the office with findings of a high bladder neck and BPH. After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms. There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion. A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described. We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds. Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck. The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock. Hemostasis was achieved, and then a similar procedure performed in the right side. We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis. Chips were removed with Ellik evacuator. There was no bleeding at the conclusion of the procedure, and the resectoscope was removed. A #24 French three-way Foley catheter was placed with efflux of clear irrigant. The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition. | {
"text": "PREOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1. Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2. Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3. Inability to pass a Foley catheter x3.,PROCEDURES:,1. Cystoscopy.,2. Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer. His history dates back to 2003 when he had a non-muscle invasive bladder cancer. He had multiple cystoscopies and followups since that time with no evidence of recurrence. However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ. Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities. I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites. We elected to allow his bladder to recover before starting the BCG. We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter. I repeated a cystoscopy in the office with findings of a high bladder neck and BPH. After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms. There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion. A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described. We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds. Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck. The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock. Hemostasis was achieved, and then a similar procedure performed in the right side. We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis. Chips were removed with Ellik evacuator. There was no bleeding at the conclusion of the procedure, and the resectoscope was removed. A #24 French three-way Foley catheter was placed with efflux of clear irrigant. The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c394873a-6395-46a8-9fd0-35b2b9acba44 | null | Default | 2022-12-07T09:34:12.566639 | {
"text_length": 3572
} |
PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup. | {
"text": "PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup."
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c396cfc7-bc17-4824-87d7-ee6c8d770134 | null | Default | 2022-12-07T09:35:31.401986 | {
"text_length": 1999
} |
PREOPERATIVE DIAGNOSES:, Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION: ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: ,Minimal.,FLUIDS:, Crystalloid.,BRIEF HISTORY: ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected. He has received BCG. The patient is doing well. The patient was supposed to come to the OR for surveillance biopsy and pyelograms. The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc. Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed. The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. The sac was turned upside down and sutures were placed. Careful attention was made to ensure that the cord was open. The testicle was in normal orientation throughout the entire procedure. The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion. Orchiopexy was done at 3 different locations. Hemostasis was obtained using electrocautery. The sac was closed using 4-0 Vicryl. The sac was turned upside down so that when it heals, the fluid would not recollect. The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied. Incision measured about 2 cm in size. Subsequently using ACMI cystoscope, a cystoscopy was performed. The urethra appeared normal. There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder. There was a short prostatic fossa. The bladder appeared normal. There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance. There were no papillary tumors or stones inside the bladder. Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal. A cold cup biopsy of the bladder was done and was fulgurated for hemostasis. The patient tolerated the procedure well. The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy. No heavy lifting, pushing, or pulling. Plan was to follow up in about 2 months. | {
"text": "PREOPERATIVE DIAGNOSES:, Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION: ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:, Spinal.,ESTIMATED BLOOD LOSS: ,Minimal.,FLUIDS:, Crystalloid.,BRIEF HISTORY: ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected. He has received BCG. The patient is doing well. The patient was supposed to come to the OR for surveillance biopsy and pyelograms. The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc. Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed. Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed. The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR. Anesthesia was applied. The patient was placed in dorsal lithotomy position. The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn. The sac was turned upside down and sutures were placed. Careful attention was made to ensure that the cord was open. The testicle was in normal orientation throughout the entire procedure. The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion. Orchiopexy was done at 3 different locations. Hemostasis was obtained using electrocautery. The sac was closed using 4-0 Vicryl. The sac was turned upside down so that when it heals, the fluid would not recollect. The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied. Incision measured about 2 cm in size. Subsequently using ACMI cystoscope, a cystoscopy was performed. The urethra appeared normal. There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder. There was a short prostatic fossa. The bladder appeared normal. There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance. There were no papillary tumors or stones inside the bladder. Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal. A cold cup biopsy of the bladder was done and was fulgurated for hemostasis. The patient tolerated the procedure well. The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy. No heavy lifting, pushing, or pulling. Plan was to follow up in about 2 months."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c398a233-d4f6-4103-8d44-1d0bea880790 | null | Default | 2022-12-07T09:33:50.434414 | {
"text_length": 2998
} |
HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks. | {
"text": "HISTORY OF PRESENT ILLNESS:, This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds.,HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. ,NECK: Supple. JVP is flat. Carotid upstroke is good. ,LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex.,ABDOMEN: Soft. There is no hepatosplenomegaly.,EXTREMITIES: Patient has 1+ pedal edema.,MEDICATIONS: , ,1. Ambien 10 mg at bedtime p.r.n.,2. Coumadin 7.5 mg daily.,3. Diovan 320 mg daily.,4. Lantus insulin 50 units in the morning.,5. Lasix 80 mg daily.,6. Novolin R p.r.n.,7. Toprol XL 100 mg daily.,8. Flovent 100 mcg twice a day.,DIAGNOSES:,1. Atherosclerotic coronary vascular disease with old myocardial infarction.,2. Moderate to severe LV systolic dysfunction.,3. Diabetes mellitus.,4. Diabetic nephropathy and renal failure.,5. Status post ICD implantation.,6. New onset of atrial fibrillation.,7. Chronic Coumadin therapy.,PLAN:,1. Continue present therapy.,2. Patient will be seen again in my office in four weeks."
} | [
{
"label": " Office Notes",
"score": 1
}
] | Argilla | null | null | false | null | c39b23c1-4464-4ea3-8a4a-e77ea8de5b67 | null | Default | 2022-12-07T09:36:47.642565 | {
"text_length": 2107
} |
SUBJECTIVE:, This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker. No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:, Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:, The patient has very dry, cracked hands bilaterally.,IMPRESSION:, Hand dermatitis.,TREATMENT:,1. Discussed further treatment with the patient and her interpreter.,2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit. | {
"text": "SUBJECTIVE:, This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker. No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:, Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:, The patient has very dry, cracked hands bilaterally.,IMPRESSION:, Hand dermatitis.,TREATMENT:,1. Discussed further treatment with the patient and her interpreter.,2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit."
} | [
{
"label": " Dermatology",
"score": 1
}
] | Argilla | null | null | false | null | c3a931b4-f95e-4d3b-921d-3225b6124a29 | null | Default | 2022-12-07T09:39:19.208993 | {
"text_length": 1542
} |
SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D. | {
"text": "SUBJECTIVE:, The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times.,OBJECTIVE:, The patient is alert and oriented. General physical exam is unremarkable. Musculoskeletal exam reveals positive tenderness in both lateral epicondyles of both elbows, no effusion. Hand examination is unremarkable today. The rest of the musculoskeletal exam is unremarkable.,ASSESSMENT:, Epicondylitis, both elbows, possibly secondary to lupus flare-up.,PLAN:, We will inject both elbows with 40-mg of Kenalog mixed with 1 cc of lidocaine. The posterior approach was chosen under sterile conditions. The patient tolerated both procedures well. I will obtain CBC and urinalysis today. If the patient's pain does not improve, I will consider adding methotrexate to her therapy.,Sample Doctor M.D."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c3aaf9cb-a995-42c5-94f5-a7b6d561cfc7 | null | Default | 2022-12-07T09:36:02.905699 | {
"text_length": 1248
} |
CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.,REVIEW OF SYSTEMS:, No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:, He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said.,PAST MEDICAL HISTORY:, No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.,GENERAL: In no acute distress.,HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.,NECK: Supple.,NOSE: Dry secretions.,EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.,MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.,CHEST: Bilateral audible breath sound. No wheezes. No palpitation.,HEART: Regular rate and rhythm with no murmur.,ABDOMEN: Soft, nontender, and nondistended.,GENITOURINARY: Tanner I male with descended testes.,EXTREMITIES: Capillary refill less than 2 seconds.,LABS:, White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:, A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily., | {
"text": "CHIEF COMPLAINT:, A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:, A 5-month-old boy brought by his parents because of 2 days of cough. Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever. Mother did not measure it.,REVIEW OF SYSTEMS:, No vomiting. No diarrhea. He had runny nose started with the cough two days ago. No skin rash. No cyanosis. Pulling on his right ear. Feeding, he is bottle-fed 2 ounces every 2 hours. Mother states he urinates like 5 to 6 times a day, stools 1 time a day. He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:, He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said. Mother had good prenatal care at 4 weeks for more than 12 visits. No complications during pregnancy. Rupture of membranes happened two days before the labor. Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales. They have animals, but outside the house and father smokes outside house. No sick contacts as the mother said.,PAST MEDICAL HISTORY:, No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 100.1, heart rate 184, respiratory rate 48. Weight 7 kg.,GENERAL: In no acute distress.,HEAD: Normocephalic and atraumatic. Open, soft, and flat anterior fontanelle.,NECK: Supple.,NOSE: Dry secretions.,EAR: Right ear full of yellowish material most probably pus and necrotic tissue. Tympanic membrane bilaterally visualized.,MOUTH: No pharyngitis. No ulcers. Moist mucous membranes.,CHEST: Bilateral audible breath sound. No wheezes. No palpitation.,HEART: Regular rate and rhythm with no murmur.,ABDOMEN: Soft, nontender, and nondistended.,GENITOURINARY: Tanner I male with descended testes.,EXTREMITIES: Capillary refill less than 2 seconds.,LABS:, White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000. CRP 6, segments 41, and bands 41. RSV positive. Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region. Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:, A 5-month-old male with 2 days of cough and 1 day of fever. Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,"
} | [
{
"label": " Pediatrics - Neonatal",
"score": 1
}
] | Argilla | null | null | false | null | c3df16df-813b-4072-8690-6d61ff5a1bde | null | Default | 2022-12-07T09:35:51.981017 | {
"text_length": 3124
} |
DIAGNOSES:,1. Pneumonia.,2. Crohn disease.,3. Anasarca.,4. Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY: ,The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory.,MEDICATIONS:,1. Prednisone.,2. Effexor.,3. Folic acid.,4. Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1. Small bowel resections.,2. Appendectomy.,3. A vasectomy.,ALLERGIES: ,He has no known drug allergies.,SOCIAL HISTORY: ,He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.,FAMILY HISTORY: ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear.,NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds.,HEART: Regular rate and rhythm.,ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable.,EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well. | {
"text": "DIAGNOSES:,1. Pneumonia.,2. Crohn disease.,3. Anasarca.,4. Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY: ,The patient is a 41-year-old gentleman with a long history of Crohn disease. He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months. He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers. This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital. He has been treated with IV antibiotics and is growing Streptococcus. At this time, he seems relatively stable although slightly dyspneic. Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities. At this time, he continues to have symptoms consistent with diarrhea and malabsorption. He also has some episodes of nausea and vomiting at times. He currently has a cough and symptoms of dyspnea. Further review of systems was not otherwise contributory.,MEDICATIONS:,1. Prednisone.,2. Effexor.,3. Folic acid.,4. Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1. Small bowel resections.,2. Appendectomy.,3. A vasectomy.,ALLERGIES: ,He has no known drug allergies.,SOCIAL HISTORY: ,He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.,FAMILY HISTORY: ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL: He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS: His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT: Sclerae anicteric. Conjunctivae normal. Nasal and oropharynx are clear.,NECK: Supple. No jugular venous pressure distention is noted. There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST: Reveals some crackles in the right chest, in the base, and in the upper lung fields. His left is relatively clear with decreased breath sounds.,HEART: Regular rate and rhythm.,ABDOMEN: Slightly protuberant. Bowel sounds are present. He is slightly tender and it is diffuse. There is no organomegaly and no ascites appreciable.,EXTREMITIES: There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC: Shows thin skin. No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3. There is no M-spike observed. His B12 is 500 with a folic acid of 11. His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1. Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2. He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate. I believe that he needs a calorie count. We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered. I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist. I will help in anyway that I can to improve the patient's laboratory abnormalities. However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time. I have explained this in detail to the patient and his family. Everybody expresses understanding and all questions were answered. At this time, follow him up during his hospital stay and plan to see him in the office as well."
} | [
{
"label": " General Medicine",
"score": 1
}
] | Argilla | null | null | false | null | c3ed1ea7-4622-4796-a17b-196496d136ed | null | Default | 2022-12-07T09:38:10.681933 | {
"text_length": 4475
} |
Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation. She is suffering from ongoing myofascitis. Her treatment plan will consist of a series of trigger point injections, which were performed today. She tolerated the procedure well. I have asked her to ice the region intermittently for 15 minutes off and on x 3. She will be followed in four weeks' time for repeat trigger point injections if indicated., | {
"text": "Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ and symmetrical. Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation. She is suffering from ongoing myofascitis. Her treatment plan will consist of a series of trigger point injections, which were performed today. She tolerated the procedure well. I have asked her to ice the region intermittently for 15 minutes off and on x 3. She will be followed in four weeks' time for repeat trigger point injections if indicated.,"
} | [
{
"label": " Office Notes",
"score": 1
}
] | Argilla | null | null | false | null | c3f8edfa-08a8-4883-ad78-5129bf2a4a37 | null | Default | 2022-12-07T09:36:42.736645 | {
"text_length": 758
} |
PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history as noted above. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.,CURRENT MEDICATIONS:,1. Triamterene/hydrochlorothiazide 37.5/25 mg.,2. Norvasc 10 mg daily.,3. Atenolol 50 mg a day.,4. Atacand 32 mg a day.,5. Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.,ASSESSMENT:, This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. In the meantime, we will discharge her from our practice. Should there be confusion or difficulty getting in the senior center, we can always see her back in followup | {
"text": "PROBLEM LIST:,1. Refractory hypertension, much improved.,2. History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3. History of GI bleed in 1995.,4. History of depression.,HISTORY OF PRESENT ILLNESS:, This is a return visit to the renal clinic for this patient. She is an 85-year-old woman with history as noted above. Her last visit was approximately four months ago. Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. She is not reporting any untoward side effect. She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. She has no orthopnea. Her exercise capacity is about the same. The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. No history of extremity pain.,CURRENT MEDICATIONS:,1. Triamterene/hydrochlorothiazide 37.5/25 mg.,2. Norvasc 10 mg daily.,3. Atenolol 50 mg a day.,4. Atacand 32 mg a day.,5. Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. THORAX: Revealed lungs that are clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3. I could not hear murmur today. ABDOMEN: Above plane, but nontender. EXTREMITIES: Revealed no edema.,ASSESSMENT:, This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. In the meantime, we will discharge her from our practice. Should there be confusion or difficulty getting in the senior center, we can always see her back in followup"
} | [
{
"label": " General Medicine",
"score": 1
}
] | Argilla | null | null | false | null | c3fef6d9-c8f2-4abb-a3aa-43a6ba60cf46 | null | Default | 2022-12-07T09:38:00.082790 | {
"text_length": 2478
} |
PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,ENDOSCOPIC CARPAL TUNNEL RELEASE:, With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release). EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well. | {
"text": "PREOPERATIVE DIAGNOSIS: ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,POSTOPERATIVE DIAGNOSIS:, ,1. Left carpal tunnel syndrome.,2. de Quervain's tenosynovitis.,OPERATIONS PERFORMED: ,1. Endoscopic carpal tunnel release.,2. de Quervain's release.,ANESTHESIA:, I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS:, None.,PROCEDURE IN DETAIL: ,ENDOSCOPIC CARPAL TUNNEL RELEASE:, With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated at 290 mm/Hg. Construction lines were made on the left palm to identify the ring ray. A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. Blunt dissection exposed the antebrachial fascia. Hemostasis was obtained with bipolar cautery. A distal-based window in the antebrachial fascia was then fashioned. Care was taken to protect the underlying contents. A proximal forearm fasciotomy was performed under direct vision. A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface. Hamate sounds were then used to palpate the hook of hamate. The endoscopic instrument was then inserted into the proximal incision. The transverse carpal ligament was easily visualized through the portal. Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window. The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision. After complete division o the transverse carpal ligament, the instrument was reinserted. Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch. Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips. The tourniquet was deflated. The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.,DE QUERVAIN'S RELEASE: , With the patient under adequate regional anesthesia applied by surgeon using 1% plain Xylocaine, the upper extremity was prepped and draped in a sterile manner. The arm was exsanguinated. The tourniquet was elevated to 290 mm/Hg. A transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel. Using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field. The first dorsal tunnel was then identified. The first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de Quervain's release). EPB and APL tendons were inspected and found to be completely free. The radial sensory nerve was inspected and found to be without damage.,The skin was closed with a running 3-0 Prolene subcuticular stitch and Steri-Strips were applied and, over the Steri-Strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position. The tourniquet was deflated. The patient was returned to the holding area in satisfactory condition, having tolerated the procedure well."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c4004cc3-915e-4b4b-9e1a-13240ab6a26e | null | Default | 2022-12-07T09:34:04.541981 | {
"text_length": 3577
} |
REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future. | {
"text": "REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access and to protect her airway at a time when it is either going to heal enough to improve and allow decannulation or eventually prove that she will need laryngotracheoplasty. Dr. X is following The patient for this and currently plans are to perform a repeat endoscopic exam every couple of months to assist the status of her airway caliber.,The patient had a laparoscopic fundoplication and gastrostomy on 10/05/2007. She has done well since that time. She has had some episodes of retching intermittently and these seemed to be unpredictable. She also had some diarrhea and poor feeding tolerance about a week ago but that has also resolved. The patient currently takes about 1 ounce to 1.5 ounce of her feedings by mouth and the rest is given by G-tube. She seems otherwise happy and is not having an excessive amount of stools. Her parents have not noted any significant problems with the gastrostomy site.,The patient's exam today is excellent. Her belly is soft and nontender. All of her laparoscopic trocar sites are healing with a normal amount of induration, but there is no evidence of hernia or infection. We removed The patient's gastrostomy button today and showed her parents how to reinsert one without difficulty. The site of the gastrostomy is excellent. There is not even a hint of granulation tissue or erythema, and I am very happy with the overall appearance.,IMPRESSION: , The patient is doing exceptionally well status post laparoscope fundoplication and gastrostomy. Hopefully, the exquisite control of acid reflux by fundoplication will help her airway heal, and if she does well, allow decannulation in the future. If she does require laryngotracheoplasty, the protection from acid reflux will be important to healing of that procedure as well.,PLAN: ,The patient will follow up as needed for problems related to gastrostomy. We will see her when she comes in the hospital for endoscopic exams and possibly laryngotracheoplasty in the future."
} | [
{
"label": " Pediatrics - Neonatal",
"score": 1
}
] | Argilla | null | null | false | null | c40776b7-890e-48e5-841e-663cb8421b45 | null | Default | 2022-12-07T09:35:49.973496 | {
"text_length": 2309
} |
PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion. The IV catheter was inserted into the vein on the lower surface of the left forearm. Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa. The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula. Hemostasis was obtained. The wound was closed in layers with PDS sutures. Sterile dressing was applied. The patient was taken to recovery room in stable condition. | {
"text": "PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion. The IV catheter was inserted into the vein on the lower surface of the left forearm. Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa. The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula. Hemostasis was obtained. The wound was closed in layers with PDS sutures. Sterile dressing was applied. The patient was taken to recovery room in stable condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c40bc24d-82a2-47b7-94c6-e76e909f9e67 | null | Default | 2022-12-07T09:34:37.524144 | {
"text_length": 1064
} |
CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:, Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES: ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. Hypertension.,2. GERD.,3. Osteoarthritis.,4. Status post tonsillectomy.,5. Status post hysterectomy.,6. Status post bilateral cataract surgery.,7. Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY: ,She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT: | {
"text": "CHIEF COMPLAINT: , Aplastic anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 72-year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,CURRENT MEDICATIONS:, Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.,ALLERGIES: ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1. Hypertension.,2. GERD.,3. Osteoarthritis.,4. Status post tonsillectomy.,5. Status post hysterectomy.,6. Status post bilateral cataract surgery.,7. Esophageal stricture status post dilatation approximately four times.,SOCIAL HISTORY: ,She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.,FAMILY HISTORY: , Her sister had breast cancer.,PHYSICAL EXAM:,VIT:"
} | [
{
"label": " SOAP / Chart / Progress Notes",
"score": 1
}
] | Argilla | null | null | false | null | c4147dc0-8bbf-4618-8764-6e57c8b63835 | null | Default | 2022-12-07T09:35:03.100851 | {
"text_length": 1564
} |
OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room. After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray. After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium. After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate. A 45-degree forceps then used to open up the maxillary sinus. There was some prominent tissue and just superior to this, the anterior ethmoid was opened. The 45-degree forceps was then used to open the maxillary sinus ostium. This was enlarged with backbiting rongeur. After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa. After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate. There was noted to have prominence in the anterior ethmoidal area. This was then opened with 45-degree forceps. This mucosa was then removed from the anterior area. The maxillary sinus ostium was then opened with 45-degree forceps. Tissue was removed from this area. This was sent as right maxillary mucosa. After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus. Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally. This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction. After this was completed, a septoplasty was performed. The incision was made with a #15 blade Bard-Parker knife. The flap was then elevated, overlying the spur that was protruding into the right nasal cavity. This was excised with a #15 blade Bard-Parker knife. The tissue was then laid back in position. After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx. , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon. The patient was then awakened and taken to recovery room in good condition. | {
"text": "OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room. After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray. After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium. After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate. A 45-degree forceps then used to open up the maxillary sinus. There was some prominent tissue and just superior to this, the anterior ethmoid was opened. The 45-degree forceps was then used to open the maxillary sinus ostium. This was enlarged with backbiting rongeur. After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa. After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate. There was noted to have prominence in the anterior ethmoidal area. This was then opened with 45-degree forceps. This mucosa was then removed from the anterior area. The maxillary sinus ostium was then opened with 45-degree forceps. Tissue was removed from this area. This was sent as right maxillary mucosa. After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus. Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally. This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction. After this was completed, a septoplasty was performed. The incision was made with a #15 blade Bard-Parker knife. The flap was then elevated, overlying the spur that was protruding into the right nasal cavity. This was excised with a #15 blade Bard-Parker knife. The tissue was then laid back in position. After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx. , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon. The patient was then awakened and taken to recovery room in good condition."
} | [
{
"label": " ENT - Otolaryngology",
"score": 1
}
] | Argilla | null | null | false | null | c4197568-c73a-425e-ad14-9a5d918650b9 | null | Default | 2022-12-07T09:38:48.310630 | {
"text_length": 2761
} |
REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you. | {
"text": "REASON FOR CONSULTATION:, Regarding weakness and a history of polymyositis.,HISTORY OF PRESENT ILLNESS:, The patient is an 87-year-old white female who gives a history of polymyositis diagnosed in 1993. The patient did have biopsy of the quadriceps muscle performed at that time which, per her account, did show an abnormality. She was previously followed by Dr. C, neurology, over several years but was last followed up in the last three to four years. She is also seeing Dr. R at rheumatology in the past. Initially, she was treated with steroids but apparently was intolerant of that. She was given other therapy but she is unclear of the details of that. She has had persistent weakness of the bilateral lower extremities and has ambulated with the assistance of a walker for many years. She has also had a history of spine disease though the process there is not known to me at this time.,She presented on February 1, 2006 with productive cough, fevers and chills, left flank rash and pain there as well as profound weakness. Since admission, she has been diagnosed with a left lower lobe pneumonic process as well as shingles and is on therapy for both. She reports that strength in the proximal upper extremities has remained good. However, she has no grip strength. Apparently, this has been progressive over the last several years as well. She also presently has virtually no strength in the lower extremities and that is worse within the last few days. Prior to admission, she has had cough with mild shortness of breath. Phlegm has been dark in color. She has had reflux and occasional dysphagia. She has also had constipation but no other GI issues. She has no history of seizure or stroke like symptoms. She occasionally has headaches. No vision changes. Other than the left flank skin changes, she has had no other skin issues. She does have a history of DVT but this was 30 to 40 years ago. No history of dry eyes or dry mouth. She denies chest pain at present.,PAST MEDICAL AND SURGICAL HISTORY:, Hysterectomy, cholecystectomy, congestive heart failure, hypertension, history of DVT, previous colonoscopy that was normal, renal artery stenosis.,MEDICATIONS:, Medications prior to admission: Os-Cal, Zyrtec, potassium, Plavix, Bumex, Diovan.,CURRENT MEDICATIONS:, Acyclovir, azithromycin, ceftriaxone, Diovan, albuterol, Robitussin, hydralazine, Atrovent.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, She is a widow. She has 8 children that are healthy with the exception of one who has coronary artery disease and has had bypass. She also has a son with lumbar spine disease. No tobacco, alcohol or IV drug abuse.,FAMILY HISTORY:, No history of neurologic or rheumatologic issues.,REVIEW OF SYSTEMS:, As above.,PHYSICAL EXAMINATION:,VITAL SIGNS: She is afebrile. Current temperature 98. Respirations 16, heart rate 80 to 90. Blood pressure 114/55.,GENERAL APPEARANCE: She is alert and oriented and in no acute distress. She is pleasant. She is reclining in the bed.,HEENT: Pupils are reactive. Sclera are clear. Oropharynx is clear.,NECK: No thyromegaly. No lymphadenopathy.,CARDIOVASCULAR: Heart is regular rate and rhythm.,RESPIRATORY: Lungs have a few rales only.,ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No hepatosplenomegaly.,EXTREMITIES: No edema.,SKIN: Left flank dermatome with vesicular rash that is red and raised consistent with zoster.,JOINTS: No synovitis anywhere. Strength is 5/5 in the proximal upper extremities. Proximal lower extremities are 0 out of 5. She has no grip strength at present.,NEUROLOGICAL: Cranial nerves II through XII grossly intact. Reflexes 2/4 at the biceps, brachial radialis, triceps. Nil out of four at the patella and Achilles bilaterally. Sensation seems normal. Chest x-ray shows COPD, left basilar infiltrate, cardiomegaly, atherosclerotic changes.,LABORATORY DATA:, White blood cell count 6.1, hemoglobin 11.9, platelets 314,000. Sed rate 29 and 30. Electrolytes: Sodium 134, potassium 4.9, creatinine 1.2, normal liver enzymes. TSH is slightly elevated at 5.38. CPK 36, BNP 645. Troponin less than 0.04.,IMPRESSION:,1. The patient has a history of polymyositis, apparently biopsy proven with a long standing history of bilateral lower extremity weakness. She has experienced dramatic worsening in the last 24 hours of the lower extremity weakness. This in the setting of an acute illness, presumably a pneumonic process.,2. She also gives a history of spine disease though the details of that process are not available either.,The question raised at this time is of recurrence in inflammatory myopathy which would need to include not only polymyositis but also inclusion body myositis versus progressive spine disease versus weakness secondary to acute illness versus neuropathic process versus other.,3. Zoster of the left flank.,4. Left lower lobe pneumonic process.,5. Elevation of the thyroid stimulating hormone.,RECOMMENDATIONS:,1. I have asked Dr. C to see the patient and he has done so tonight. He is planning for EMG nerve conduction study in the morning.,2. I would consider further spine evaluation pending review of the EMG nerve conduction study.,3. Agree with supportive care being administered thus far and will follow along with you."
} | [
{
"label": " Rheumatology",
"score": 1
}
] | Argilla | null | null | false | null | c4240ac8-f4f2-42d7-aa12-0394d0c5322c | null | Default | 2022-12-07T09:35:06.166185 | {
"text_length": 5245
} |
PREOPERATIVE DIAGNOSES:, Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:, Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped. He was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. He did receive antibiotics post procedure. He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. Burr hole was drilled with the cranial twist drill. The dura was punctured with a twist drill. A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless. The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal. None replaced. | {
"text": "PREOPERATIVE DIAGNOSES:, Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:, Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped. He was prepped with ChloraPrep and Betadine. Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000. He did receive antibiotics post procedure. He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion. A self-retaining retractor was placed. Burr hole was drilled with the cranial twist drill. The dura was punctured with a twist drill. A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle. The pressure was initially high. The CSF was clear and colorless. The CSF drainage rapidly tapered off because of the brain swelling. With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull. There was intermittent drainage of CSF after that. The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture. The patient tolerated the procedure well. No complications. Sponge and needle counts were correct. Blood loss is minimal. None replaced."
} | [
{
"label": " Neurosurgery",
"score": 1
}
] | Argilla | null | null | false | null | c426e416-d1ae-4724-93f5-61d5ce8dc72f | null | Default | 2022-12-07T09:37:03.031041 | {
"text_length": 1523
} |
SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening. He finished up his Augmentin, by a day or two later he was off the Lortab. Mom has not noticed any unusual voice change. No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce. He has not had any nasal discharge or ever had any bleeding. He seems to be breathing better.,OBJECTIVE:, Exam looks good. The pharynx is well healed. Tongue mobility is normal. Voice sounds clear. Nasal passages reveal no discharge or crusting.,RECOMMENDATION:, I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive. He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth. It is okay to chew gum and it is okay to eat crunchy foods such as potato chips. The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well. There are no other restrictions or limitations. I told Mom, I had written to Dr. XYZ to let her know of the findings. The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed. He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure. | {
"text": "SUBJECTIVE:, A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago. Also, I cleaned out his maxillary sinuses. Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue. The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening. He finished up his Augmentin, by a day or two later he was off the Lortab. Mom has not noticed any unusual voice change. No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce. He has not had any nasal discharge or ever had any bleeding. He seems to be breathing better.,OBJECTIVE:, Exam looks good. The pharynx is well healed. Tongue mobility is normal. Voice sounds clear. Nasal passages reveal no discharge or crusting.,RECOMMENDATION:, I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive. He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth. It is okay to chew gum and it is okay to eat crunchy foods such as potato chips. The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well. There are no other restrictions or limitations. I told Mom, I had written to Dr. XYZ to let her know of the findings. The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed. He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure."
} | [
{
"label": " ENT - Otolaryngology",
"score": 1
}
] | Argilla | null | null | false | null | c428929b-afce-4a7a-9a49-66a8c09e56aa | null | Default | 2022-12-07T09:38:47.798159 | {
"text_length": 1797
} |
HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this. | {
"text": "HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c434053f-ec4d-4d2c-98c2-8cec5c889a5a | null | Default | 2022-12-07T09:39:33.454109 | {
"text_length": 4892
} |
PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:, The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel. There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion. A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg. Perioperative antibiotics were infused. Time-out procedure was called. The medial epicondyle and the olecranon tip were well palpated. The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally. The ulnar nerve was identified proximally. It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply. The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches. The ulnar nerve was well-isolated before it entered the cubital tunnel. The arch of the FCU was well defined. The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization. Distally, the dissection was carried between the 2 heads of the FCU. Decompression of the nerve was performed between the heads of the FCU. The muscular branches were well protected. Similarly, the cutaneous branches in the arm and forearm were well protected. The venous plexus proximally and distally were well protected. The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it. Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected. Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended. There was no evidence of any subluxation. Satisfactory decompression was performed. Tourniquet was released. Hemostasis was achieved. Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples. A well-padded dressing was applied. The patient was then extubated and transferred to the recovery room in stable condition. There were no intraoperative complications noted. The patient tolerated the procedure very well. | {
"text": "PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:, The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel. There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion. A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg. Perioperative antibiotics were infused. Time-out procedure was called. The medial epicondyle and the olecranon tip were well palpated. The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally. The ulnar nerve was identified proximally. It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply. The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches. The ulnar nerve was well-isolated before it entered the cubital tunnel. The arch of the FCU was well defined. The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization. Distally, the dissection was carried between the 2 heads of the FCU. Decompression of the nerve was performed between the heads of the FCU. The muscular branches were well protected. Similarly, the cutaneous branches in the arm and forearm were well protected. The venous plexus proximally and distally were well protected. The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it. Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected. Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended. There was no evidence of any subluxation. Satisfactory decompression was performed. Tourniquet was released. Hemostasis was achieved. Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples. A well-padded dressing was applied. The patient was then extubated and transferred to the recovery room in stable condition. There were no intraoperative complications noted. The patient tolerated the procedure very well."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c4423e19-b4cb-452f-a978-185aae66121b | null | Default | 2022-12-07T09:35:58.854013 | {
"text_length": 2689
} |
PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time. | {
"text": "PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE: ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________ was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS: ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:, Stable.,PROCEDURE: ,The patient placed supine under general anesthesia. First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep. Sterile dressing was placed. The laryngeal monitoring was noted to be working fine. Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level. The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found. Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments. The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed. No bleeding was seen. There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature. After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature. After this was completed, no bleeding was seen. The laryngeal nerve could be seen and intact and then Rubber band drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally. Procedure was then terminated at that time."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c4542837-7a77-4600-bc14-9c496ba4386c | null | Default | 2022-12-07T09:33:19.240768 | {
"text_length": 2804
} |
DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition. | {
"text": "DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition."
} | [
{
"label": " Obstetrics / Gynecology",
"score": 1
}
] | Argilla | null | null | false | null | c48de8db-27c3-440d-872b-c0c0f232c752 | null | Default | 2022-12-07T09:36:59.317744 | {
"text_length": 811
} |
PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1% Mydriacyl, and Iopidine was instilled. The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied. A total of | {
"text": "PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane. The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1% Mydriacyl, and Iopidine was instilled. The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied. A total of"
} | [
{
"label": " Ophthalmology",
"score": 1
}
] | Argilla | null | null | false | null | c48eedcc-3b28-4e6b-a1dc-d679df094c4e | null | Default | 2022-12-07T09:36:33.237440 | {
"text_length": 692
} |
DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age. | {
"text": "DESCRIPTION OF RECORD: ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system. Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical. During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly. The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age."
} | [
{
"label": " Neurology",
"score": 1
}
] | Argilla | null | null | false | null | c49f0bff-4bf8-427d-a230-7b92a0be8f0e | null | Default | 2022-12-07T09:37:27.367332 | {
"text_length": 970
} |
HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation. | {
"text": "HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation."
} | [
{
"label": " Gastroenterology",
"score": 1
}
] | Argilla | null | null | false | null | c4b55fe0-6433-44c4-8b09-e19f26eed0ab | null | Default | 2022-12-07T09:38:42.276352 | {
"text_length": 1919
} |
HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to "pop into place." He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70 | {
"text": "HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to \"pop into place.\" He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:, He has diabetes, but this is well controlled. He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs: Blood pressure 130/70"
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c4c2afc1-2ea0-4855-abd5-21d1c36816bd | null | Default | 2022-12-07T09:40:01.386083 | {
"text_length": 2357
} |
REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS: | {
"text": "REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps. The patient reports her first polyps noted at the age of 50. She has had colonoscopies required every five years and every time she has polyps were found. She reports that of her 11 brothers and sister 7 have had precancerous polyps. She does have an identical twice who is the one of the 11 who has never had a history of polyps. She also has history of several malignancies in the family. Her father died of a brain tumor at the age of 81. There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. Her sister died at the age of 65 breast cancer. She has two maternal aunts with history of lung cancer both of whom were smoker. Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. There is no other cancer history.,PAST MEDICAL HISTORY:, Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin. She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married. She was born and raised in South Dakota. She moved to Colorado 37 years ago. She attended collage at the Colorado University. She is certified public account. She does not smoke. She drinks socially.,REVIEW OF SYSTEMS: ,The patient denies any dark stool or blood in her stool. She has had occasional night sweats and shortness of breath, and cough associated with her asthma. She also complains of some acid reflux as well as anxiety. She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee. The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:"
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c4d663a4-a77f-429a-8773-6adf184ac225 | null | Default | 2022-12-07T09:40:11.412169 | {
"text_length": 1898
} |
PROCEDURE:, A 21-channel digital electroencephalogram was performed on a patient in the awake state. Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity. Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted. The episodes last from approximately1 to 7 seconds. The episodes are exacerbated by hyperventilation.,IMPRESSION:, Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation. This activity could represent true petit mal epilepsy. Clinical correlation is suggested. | {
"text": "PROCEDURE:, A 21-channel digital electroencephalogram was performed on a patient in the awake state. Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity. Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted. The episodes last from approximately1 to 7 seconds. The episodes are exacerbated by hyperventilation.,IMPRESSION:, Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation. This activity could represent true petit mal epilepsy. Clinical correlation is suggested."
} | [
{
"label": " Neurology",
"score": 1
}
] | Argilla | null | null | false | null | c4f48b3e-cef6-44b1-b93b-f27157d42033 | null | Default | 2022-12-07T09:37:26.895389 | {
"text_length": 663
} |
REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.,REVIEW OF SYSTEMS: ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs: Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General: She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT: Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.,Neck: Trachea appeared to be in the midline.,Chest: Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular: Showed a normal sinus rhythm without murmur.,Abdomen: Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities: Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.,Neurological: From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:, A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1. For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2. As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3. I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.,4. The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then. | {
"text": "REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures. Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone. The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time. Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted. There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.,REVIEW OF SYSTEMS: ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs: Weight was 15.6 kg. She was afebrile. Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General: She was awake, alert, and oriented. She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT: Showed normocephalic and atraumatic head. Her conjunctivae were nonicteric and sclerae were clear. Her eye movements were conjugate in nature. Her tongue and mucous membranes were moist.,Neck: Trachea appeared to be in the midline.,Chest: Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular: Showed a normal sinus rhythm without murmur.,Abdomen: Showed soft, nontender, and nondistended, with good bowel sounds. There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities: Showed IV placement in the right upper extremity with appropriate restraints from the IV. There was no evidence of clubbing, cyanosis or edema throughout. She had no functional deformities in any of her peripheral limbs.,Neurological: From neurological standpoint, her cranial nerves were grossly intact throughout. Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation. Her overall resting tone was normal. Sensory examination was grossly intact to light touch throughout the upper and lower extremities. Reflexes were 1+ in bilateral patella. Toes were downgoing bilaterally. Coordination showed accurate striking ability and good rapid alternating movements. Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:, A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1. For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2. As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day. If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3. I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings. EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results. The patient has been discharged and we will contact the family as an outpatient.,4. The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c4f5ac4d-9758-4c52-b509-c23ad9c21296 | null | Default | 2022-12-07T09:39:42.386778 | {
"text_length": 4860
} |
INDICATIONS:, | {
"text": "INDICATIONS:,"
} | [
{
"label": " Cardiovascular / Pulmonary",
"score": 1
}
] | Argilla | null | null | false | null | c4f5d212-6720-4567-9da6-ee37114c477a | null | Default | 2022-12-07T09:40:25.788613 | {
"text_length": 13
} |
PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gore exclusive device was used 3 pieces were used to effect the repair. We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm. The right hypogastric artery had been previously coiled off. Left common femoral artery was used for the _____ side. We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area. It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally. The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side. The calibrated aortogram was the done. We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries. We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery. As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately. A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries. The area was ballooned aggressively. It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas. Both femoral arteries were repaired by primary suture technique. Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly. Meticulous hemostasis was achieved. Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied. Sponge and needle counts were reported as correct. The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition. | {
"text": "PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gore exclusive device was used 3 pieces were used to effect the repair. We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm. The right hypogastric artery had been previously coiled off. Left common femoral artery was used for the _____ side. We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area. It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally. The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side. The calibrated aortogram was the done. We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries. We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery. As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately. A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries. The area was ballooned aggressively. It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas. Both femoral arteries were repaired by primary suture technique. Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly. Meticulous hemostasis was achieved. Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied. Sponge and needle counts were reported as correct. The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c5031e50-57f4-44e4-8525-4d6e09896518 | null | Default | 2022-12-07T09:34:03.679481 | {
"text_length": 3016
} |
CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn. | {
"text": "CHIEF COMPLAINT:, Palpitations.,CHEST PAIN / UNSPECIFIED ANGINA PECTORIS HISTORY:, The patient relates the recent worsening of chronic chest discomfort. The quality of the pain is sharp and the problem started 2 years ago. Pain radiates to the back and condition is best described as severe. Patient denies syncope. Beyond baseline at present time. Past work up has included 24 hour Holter monitoring and echocardiography. Holter showed PVCs.,PALPITATIONS HISTORY:, Palpitations - frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.,VALVULAR DISEASE HISTORY:, Patient has documented mitral valve prolapse on echocardiography in 1992.,PAST MEDICAL HISTORY:, No significant past medical problems. Mitral Valve Prolapse.,FAMILY MEDICAL HISTORY:, CAD.,OB-GYN HISTORY:, The patients last child birth was 1997. Para 3. Gravida 3.,SOCIAL HISTORY:, Denies using caffeinated beverages, alcohol or the use of any tobacco products.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, Inderal 20 prn.,REVIEW OF SYSTEMS:, Generally healthy. The patient is a good historian.,ROS Head and Eyes: Denies vision changes, light sensitivity, blurred vision, or double vision.,ROS Ear, Nose and Throat: The patient denies any ear, nose or throat symptoms.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ROS Genitourinary: Patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ROS Gynecological: Denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ROS Musculoskeletal: The patient denies any past or present problems related to the musculoskeletal system.,ROS Extremities: The patient denies any extremities complaints.,ROS Cardiovascular: As per HPI.,EXAMINATION:,Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.,Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted.,Range of motion is normal. There is no cyanosis, clubbing or edema.,General: Healthy appearing, well developed,. The patient is in no acute distress.,Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.,Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.,Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.,Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.,Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.,IMPRESSION / DIAGNOSIS:, Mitral Valve Prolapse. Palpitations.,TESTS ORDERED:, Cardiac tests: Echocardiogram.,MEDICATION PRESCRIBED:, ,Cardizem 30-60 qid prn."
} | [
{
"label": " Cardiovascular / Pulmonary",
"score": 1
}
] | Argilla | null | null | false | null | c504f29b-92ca-444b-9479-8a4ae4b44a0f | null | Default | 2022-12-07T09:40:48.020114 | {
"text_length": 3270
} |
PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow. | {
"text": "PREOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1. Uncontrolled open angle glaucoma, left eye.,2. Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Negligible.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines. In the preoperative area, the patient received pilocarpine drops. The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain. Approximately 3 mL were given. The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye. During the draping process, care was taken to isolate the lashes. A screw type speculum was inserted to maintain patency of lids. A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade. This was approximately one-half scleral depth in thickness. A crescent blade was then used to dissect forward the clear cornea. Hemostasis was again achieved with wet-field cautery. A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. The site was then profusely irrigated with balanced salt solution. A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed. Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps. The iris was then repositioned into the eye and the anterior chamber was inflated with BSS. The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle. BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. Antibiotic and steroid drops were placed in the eye as was homatropine 5%. The antibiotic consisted of Vigamox and the steroid was Econopred Plus. A patch and shield were placed over the eye after the drape was removed. The patient was taken to the recovery room in good condition. She will be seen in followup in the office tomorrow."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c50a8bff-1178-468a-bf4a-5f8e8b9fcd65 | null | Default | 2022-12-07T09:33:02.540396 | {
"text_length": 3117
} |
PREOPERATIVE DIAGNOSIS: , Shunt malfunction. The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:, Shunt malfunction. The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:, Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:, None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner. The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn. The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped. Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around. We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction. A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle. It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures. The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips. The patient was awakened and extubated having tolerated the procedure well without complications. It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest. | {
"text": "PREOPERATIVE DIAGNOSIS: , Shunt malfunction. The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:, Shunt malfunction. The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:, Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:, None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:, After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner. The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn. The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped. Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around. We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction. A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle. It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures. The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips. The patient was awakened and extubated having tolerated the procedure well without complications. It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest."
} | [
{
"label": " Neurosurgery",
"score": 1
}
] | Argilla | null | null | false | null | c50d8902-d11c-41ad-ac99-a3c087742d15 | null | Default | 2022-12-07T09:37:04.819807 | {
"text_length": 2451
} |
EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of the common bile duct up to 1 cm. There is also dilatation of the pancreatic duct that measures up to 3 mm. There is caliectasis in the right kidney. The bladder is significantly distended measuring 937 cc in volume. The caliectasis in the right kidney may be secondary to back pressure from the distended bladder. The aorta is normal in caliber., ,IMPRESSION:,1. Dilated common duct as well as pancreatic duct as described. Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass. The findings could reflect changes of cholecystectomy. ,2. Significantly distended bladder with probably resultant caliectasis in the right kidney. Clinical correlation recommended. | {
"text": "EXAM: , Ultrasound Abdomen., ,REASON FOR EXAM: , Elevated liver function tests., ,INTERPRETATION: , The liver demonstrates heterogeneously increased echotexture with significant fatty infiltration. The gallbladder is surgically absent. There is no fluid collection in the cholecystectomy bed. There is dilatation of the common bile duct up to 1 cm. There is also dilatation of the pancreatic duct that measures up to 3 mm. There is caliectasis in the right kidney. The bladder is significantly distended measuring 937 cc in volume. The caliectasis in the right kidney may be secondary to back pressure from the distended bladder. The aorta is normal in caliber., ,IMPRESSION:,1. Dilated common duct as well as pancreatic duct as described. Given the dilatation of these two ducts, ERCP versus MRCP is recommended to exclude obstructing mass. The findings could reflect changes of cholecystectomy. ,2. Significantly distended bladder with probably resultant caliectasis in the right kidney. Clinical correlation recommended."
} | [
{
"label": " Gastroenterology",
"score": 1
}
] | Argilla | null | null | false | null | c50da3df-5f0e-4f4d-92b5-08af1489523d | null | Default | 2022-12-07T09:38:24.051936 | {
"text_length": 1036
} |
INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:, Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:, Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact., | {
"text": "INDICATIONS FOR PROCEDURE:, Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia. The patient was already in the operating room under general anesthesia. Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:, Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance. The probe was placed so that the larger diameter was in the anterior-posterior position during insertion. The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography. At the end, it was removed without trauma and there was no blood tingeing. It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned. There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:, Both groins were prepped and draped. The patient was placed at 10 degrees head-up position. A Cook 4-French double-lumen 8-cm catheter kit was opened. Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin. There were several successful punctures of these vessels, but I was unable to advance Seldinger wire. After removal of the needles, the area was compressed digitally for approximately 5 minutes. There was a small hematoma that was not growing. Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds. Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath. Further observation, the capillary refill and circulation of the left leg became more than adequate. The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end. At the end of the procedure, the circulation of the leg was intact.,"
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c517c116-0845-4813-a769-be5a20470b3e | null | Default | 2022-12-07T09:33:01.531928 | {
"text_length": 2254
} |
REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient. The patient understood. All questions were answered, and informed consent was obtained. With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney. Conscious sedation was utilized with the patient being monitored. The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach. Two biopsy specimens were obtained and placed in 10% formalin solution. CT documented needle placement. Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly. I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding. The bleeding stopped. The co-axial sheath was then removed. Bandage was applied. Hemostasis was obtained. The patient was placed in the supine position. Postbiopsy CT images were then obtained. The patient's hematoma appeared stable. The patient was without complaints of pain or discomfort. The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable. The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS: Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney. Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass. Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass. There are small droplets of air within the hematoma. No hydronephrosis is identified.,CONCLUSION:,1. Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2. Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets. | {
"text": "REASON FOR EXAM: This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE: The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient. The patient understood. All questions were answered, and informed consent was obtained. With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney. Conscious sedation was utilized with the patient being monitored. The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach. Two biopsy specimens were obtained and placed in 10% formalin solution. CT documented needle placement. Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly. I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding. The bleeding stopped. The co-axial sheath was then removed. Bandage was applied. Hemostasis was obtained. The patient was placed in the supine position. Postbiopsy CT images were then obtained. The patient's hematoma appeared stable. The patient was without complaints of pain or discomfort. The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable. The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS: Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney. Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass. Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass. There are small droplets of air within the hematoma. No hydronephrosis is identified.,CONCLUSION:,1. Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2. Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets."
} | [
{
"label": " Nephrology",
"score": 1
}
] | Argilla | null | null | false | null | c52f6dfc-4b92-4a04-8a7d-8f0388ea9b96 | null | Default | 2022-12-07T09:37:40.445040 | {
"text_length": 2834
} |
REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. He ran out of prescription medications 1 month ago. In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24. White blood cell count was slightly low at 4 and platelet count was only 22,000. Abdominal ultrasound showed mild-to-moderate ascites. He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night. Dr. X was called early this morning due to hypotension, SBP in the 70s. He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE: The patient is drowsy. Morbidly obese. Height 5 feet 8 inches, body weight 182 kilos.,EYES: Slightly pale conjunctivae, icteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No rales or rubs. Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL: Globular abdomen. Soft. No guarding, no rigidity. Tender on palpation of n right upper quadrant and epigastric area. Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC: No cervical lymphadenopathy.,SKIN: Positive diffuse jaundice. No palpable subcutaneous nodules.,PSYCHIATRIC: Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000. INR 3.84, PTT more than 240. BUN and creatinine 26.8/1.2. AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85. Total CK 1198.6, LDH 873.2. Troponin 0.09, myoglobin 2792. Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria. Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:, Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures. Left knee x-rays on 01/07/09 showed advanced osteoarthritis. Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid. Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein. Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1. Septic shock.,2. Possible urinary tract infection.,3. Ascites, rule out spontaneous bacterial peritenonitis.,4. Hyperbilirubinemia, consider cholangitis.,5. Alcoholic liver disease.,6. Thrombocytopenia.,7. Hepatitis C.,8. Cryoglobulinemia.,RECOMMENDATIONS:,1. Continue with vancomycin and doripenem at this point.,2. Agree with paracentesis.,3. Send ascitic fluid for cell count, differential and cultures.,4. Follow up with result of blood cultures.,5. We will get urine culture from the specimen on admission.,6. The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup. | {
"text": "REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. He ran out of prescription medications 1 month ago. In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24. White blood cell count was slightly low at 4 and platelet count was only 22,000. Abdominal ultrasound showed mild-to-moderate ascites. He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night. Dr. X was called early this morning due to hypotension, SBP in the 70s. He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:, None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS: Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE: The patient is drowsy. Morbidly obese. Height 5 feet 8 inches, body weight 182 kilos.,EYES: Slightly pale conjunctivae, icteric sclerae. Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions.,NECK: No palpable neck masses. Thyroid is not enlarged on inspection.,RESPIRATORY: Regular inspiratory effort. No crackles or wheezes.,CARDIOVASCULAR: Regular cardiac rhythm. No rales or rubs. Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL: Globular abdomen. Soft. No guarding, no rigidity. Tender on palpation of n right upper quadrant and epigastric area. Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC: No cervical lymphadenopathy.,SKIN: Positive diffuse jaundice. No palpable subcutaneous nodules.,PSYCHIATRIC: Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000. INR 3.84, PTT more than 240. BUN and creatinine 26.8/1.2. AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85. Total CK 1198.6, LDH 873.2. Troponin 0.09, myoglobin 2792. Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria. Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:, Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures. Left knee x-rays on 01/07/09 showed advanced osteoarthritis. Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid. Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein. Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1. Septic shock.,2. Possible urinary tract infection.,3. Ascites, rule out spontaneous bacterial peritenonitis.,4. Hyperbilirubinemia, consider cholangitis.,5. Alcoholic liver disease.,6. Thrombocytopenia.,7. Hepatitis C.,8. Cryoglobulinemia.,RECOMMENDATIONS:,1. Continue with vancomycin and doripenem at this point.,2. Agree with paracentesis.,3. Send ascitic fluid for cell count, differential and cultures.,4. Follow up with result of blood cultures.,5. We will get urine culture from the specimen on admission.,6. The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c546d36f-7474-4b78-966d-6743366929e3 | null | Default | 2022-12-07T09:40:07.204415 | {
"text_length": 4566
} |
PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops. A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg. The eye was prepped with a Betadine solution and draped in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition. | {
"text": "PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine drops. A Honan balloon was placed over the eye for a period of 20 minutes at 10 mmHg. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. The Honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmHg. The eye was prepped with a Betadine solution and draped in the usual sterile fashion. A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. A 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula. Phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. Gentle vacuuming of the central posterior capsule was performed. The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,The intraocular lens was folded, inserted into the capsular bag and then un-folded. The trailing haptic was tucked underneath the anterior capsular rim. The lens was shown to center very well. Therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction. The wound was shown to be watertight. Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied and a Fox shield taped firmly in place.,The patient tolerated the procedure well and left the operating room in good condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c5530b0b-7c97-4aee-bd30-ce6fdd02ff80 | null | Default | 2022-12-07T09:34:24.954371 | {
"text_length": 2413
} |
The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS: Proximal and mid esophagus were without abnormalities.,STOMACH: Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM: Normal. | {
"text": "The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS: Proximal and mid esophagus were without abnormalities.,STOMACH: Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM: Normal."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c553d84f-a420-4137-8d6f-f78c3e5f045b | null | Default | 2022-12-07T09:34:05.695229 | {
"text_length": 588
} |
S:, The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:, Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1. Onychomycosis present, #1 right and #1 left.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails. | {
"text": "S:, The patient presents to Podiatry Clinic today for initial examination, evaluation, and treatment of her nails.,PRIMARY MEDICAL HISTORY:, Adenocarcinoma, delirium, recent dehydration, anemia, history of hypertension, and hyperlipidemia.,MEDICATIONS: , Refer to chart.,ALLERGIES: , PENICILLIN AND ASPIRIN.,O: , The patient presents in wheelchair, verbal and alert. Vascular: She has absent pedal pulses bilaterally. Trophic changes include absent hair growth and mycotic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings are temperature change and edema +1. Nails: Hypertrophic with crumbly subungual debris, # 1 right and #1 left.,A:,1. Onychomycosis present, #1 right and #1 left.,2. Peripheral vascular disease as per classic findings.,3. Pain on palpation.,P: , Nails #1 right and #1 left were debrided for length and thickness. All the nails were reduced. The patient will be seen at the request of the nursing staff for treatment of painful mycotic nails."
} | [
{
"label": " Podiatry",
"score": 1
}
] | Argilla | null | null | false | null | c55f3dbc-e75e-4ebd-886a-fe049b053e14 | null | Default | 2022-12-07T09:35:40.273562 | {
"text_length": 1005
} |
EXAM:, CT cervical spine (C-spine) for trauma.,FINDINGS:, CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height, alignment and interspacing are maintained. There is no evidence of fractures or destructive osseous lesions. There are no significant degenerative endplate or facet changes. No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine. | {
"text": "EXAM:, CT cervical spine (C-spine) for trauma.,FINDINGS:, CT examination of the cervical spine was performed without contrast. Coronal and sagittal reformats were obtained for better anatomical localization. Cervical vertebral body height, alignment and interspacing are maintained. There is no evidence of fractures or destructive osseous lesions. There are no significant degenerative endplate or facet changes. No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine."
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c565ea0f-ed44-43ce-a507-f46712b778f1 | null | Default | 2022-12-07T09:35:26.250368 | {
"text_length": 531
} |
PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:, Incompetent glottis.,OPERATION PERFORMED:,1. Fat harvesting from the upper thigh.,2. Micro-laryngoscopy.,3. Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion. A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space. After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin. After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device. Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Estimated blood loss was negligible. | {
"text": "PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:, Incompetent glottis.,OPERATION PERFORMED:,1. Fat harvesting from the upper thigh.,2. Micro-laryngoscopy.,3. Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion. A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space. After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin. After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device. Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Estimated blood loss was negligible."
} | [
{
"label": " ENT - Otolaryngology",
"score": 1
}
] | Argilla | null | null | false | null | c572caae-a34b-4656-9bba-ea99698202da | null | Default | 2022-12-07T09:38:52.153597 | {
"text_length": 1241
} |
CAUSE OF DEATH:,1. Acute respiratory failure.,2. Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1. Acute respiratory failure, probably worsened by aspiration.,2. Acute on chronic renal failure.,3. Non-Q wave myocardial infarction.,4. Bilateral lung masses.,5. Occlusive carotid disease.,6. Hypertension.,7. Peripheral vascular disease.,HOSPITAL COURSE: ,This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months. The patient was admitted again on 12/15/08, after he had been discharged the previous day. Came in with acute on chronic respiratory failure, with CO2 of 57. The patient was in rapid atrial fibrillation. RVR with a rapid ventricular response of 160 beats per minute. The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation. The patient's heart rate was controlled with IV Cardizem. Troponin was consistent with non-Q wave MI. The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease. Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology. There was also prosthetic aortic valve. The patient was admitted to Intensive Care Unit and was intubated. Pulmonary was managed by Critical Care, Dr. X.,The patient was successfully extubated. Was tapered from IV steroids and put on p.o. steroids. The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3. There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status. Wife decided catheterization should be canceled and the patient managed conservatively. The patient was transferred to the telemetry floor. While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days. The patient had nausea and vomiting. Was unable to tolerate p.o. Was put on cautious hydration. The patient went into acute respiratory distress. Intubation showed the patient had aspirated. He was in acute respiratory failure with bronchospasms and exacerbation of COPD. X-ray of chest did not show any infiltrate, but showed dilatation of the stomach. The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X. The patient was put on the vent. Overnight, the patient's condition did not improve. Continued to be severely hypoxic.,The patient expired on the morning of 12/24/08 from acute respiratory failure. | {
"text": "CAUSE OF DEATH:,1. Acute respiratory failure.,2. Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1. Acute respiratory failure, probably worsened by aspiration.,2. Acute on chronic renal failure.,3. Non-Q wave myocardial infarction.,4. Bilateral lung masses.,5. Occlusive carotid disease.,6. Hypertension.,7. Peripheral vascular disease.,HOSPITAL COURSE: ,This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months. The patient was admitted again on 12/15/08, after he had been discharged the previous day. Came in with acute on chronic respiratory failure, with CO2 of 57. The patient was in rapid atrial fibrillation. RVR with a rapid ventricular response of 160 beats per minute. The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation. The patient's heart rate was controlled with IV Cardizem. Troponin was consistent with non-Q wave MI. The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease. Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology. There was also prosthetic aortic valve. The patient was admitted to Intensive Care Unit and was intubated. Pulmonary was managed by Critical Care, Dr. X.,The patient was successfully extubated. Was tapered from IV steroids and put on p.o. steroids. The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3. There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status. Wife decided catheterization should be canceled and the patient managed conservatively. The patient was transferred to the telemetry floor. While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days. The patient had nausea and vomiting. Was unable to tolerate p.o. Was put on cautious hydration. The patient went into acute respiratory distress. Intubation showed the patient had aspirated. He was in acute respiratory failure with bronchospasms and exacerbation of COPD. X-ray of chest did not show any infiltrate, but showed dilatation of the stomach. The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X. The patient was put on the vent. Overnight, the patient's condition did not improve. Continued to be severely hypoxic.,The patient expired on the morning of 12/24/08 from acute respiratory failure."
} | [
{
"label": " Discharge Summary",
"score": 1
}
] | Argilla | null | null | false | null | c597cd3f-e519-48c0-a759-4f9d1ebb56ff | null | Default | 2022-12-07T09:39:14.489312 | {
"text_length": 2613
} |
PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition. | {
"text": "PREOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1. Right hydronephrosis.,2. Right flank pain.,3. Atypical/dysplastic urine cytology.,4. Extrarenal pelvis on the right.,5. No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1. Cystoscopy.,2. Bilateral retrograde ureteropyelograms.,3. Right ureteral barbotage for urine cytology.,4. Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS: ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability. She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone. She has some ureteral thickening in her distal right ureter. She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile. She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia. She was placed in the lithotomy position, prepped and draped in the usual sterile fashion. The 21-French cystoscope was inserted per urethra into the bladder. The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities. The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter. This was gently advanced to the mid ureter. Urine was collected for cytology. Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen. This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter. An 0.038 guidewire was then passed up through the open-ended ureteral catheter. The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis. Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected. The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level. There were no intrapelvic or calyceal stones. The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate. The ureteroscope was then removed. The cystoscope was reinserted. Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system. No evidence of extravasation or significant change in anatomy was visualized. The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system. The cystoscope was removed. Foley catheter was inserted. The patient was placed in the supine position and transferred to the recovery room in satisfactory condition."
} | [
{
"label": " Urology",
"score": 1
}
] | Argilla | null | null | false | null | c59a37af-87e3-49d7-9849-281e501f9f7e | null | Default | 2022-12-07T09:32:51.613634 | {
"text_length": 3447
} |
Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD, | {
"text": "Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,"
} | [
{
"label": " Cardiovascular / Pulmonary",
"score": 1
}
] | Argilla | null | null | false | null | c5b218e8-6371-425b-9d4c-cd27f5ff1427 | null | Default | 2022-12-07T09:40:50.417907 | {
"text_length": 411
} |
PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS: ,10 mL.,FLUIDS RECEIVED:, 300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee. Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified. Once he was anesthetized, IV antibiotics were given. The dorsal hood was retracted and cleansed. He was then sterilely prepped and draped. Stay suture of #4-0 Prolene was then placed in the glans. His urethra was calibrated to 10-French bougie-a-boule. We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum. Byers flaps were also marked. Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis. On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage. Once this was done, an electrocautery was used for hemostasis were then used. A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee. We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture. Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight. We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate. We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings. Using the curved iris scissors, we then elevated the wings even further. Again, electrocautery was used for hemostasis. An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture. There were two areas of coverage with the tissue flap relocation from the glanular wings. The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl. Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl. Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline. The extra dorsal hood tissue of preputial skin was then excised. An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline. The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself. At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing. Telfa and the surgical eye tape was then used for the final dressing. IV Toradol was given. The patient tolerated the procedure well and was in stable condition upon transfer to recovery room. | {
"text": "PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS: ,10 mL.,FLUIDS RECEIVED:, 300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee. Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified. Once he was anesthetized, IV antibiotics were given. The dorsal hood was retracted and cleansed. He was then sterilely prepped and draped. Stay suture of #4-0 Prolene was then placed in the glans. His urethra was calibrated to 10-French bougie-a-boule. We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum. Byers flaps were also marked. Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis. On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage. Once this was done, an electrocautery was used for hemostasis were then used. A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee. We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture. Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight. We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate. We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings. Using the curved iris scissors, we then elevated the wings even further. Again, electrocautery was used for hemostasis. An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture. There were two areas of coverage with the tissue flap relocation from the glanular wings. The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl. Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl. Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline. The extra dorsal hood tissue of preputial skin was then excised. An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline. The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself. At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing. Telfa and the surgical eye tape was then used for the final dressing. IV Toradol was given. The patient tolerated the procedure well and was in stable condition upon transfer to recovery room."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c5b6e941-a179-4a38-9559-c22357667207 | null | Default | 2022-12-07T09:33:50.626274 | {
"text_length": 3791
} |
EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. Rest of visualized exam nonacute/stable.,3. Left central line appropriately situated and stable.,4. Preliminary report was issued at time of dictation. Dr. X was called for results. | {
"text": "EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. Rest of visualized exam nonacute/stable.,3. Left central line appropriately situated and stable.,4. Preliminary report was issued at time of dictation. Dr. X was called for results."
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c5bd40a7-d78d-474b-8807-9af0f8f23cec | null | Default | 2022-12-07T09:35:29.869863 | {
"text_length": 904
} |
REASON FOR EXAMINATION: Face asleep.,COMPARISON EXAMINATION: None.,TECHNIQUE: Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained.,DISCUSSION: No acute intracranial abnormalities appreciated. No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections. No cortical based abnormalities appreciated. The sinuses are clear. No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION: No acute intracranial abnormalities appreciated., | {
"text": "REASON FOR EXAMINATION: Face asleep.,COMPARISON EXAMINATION: None.,TECHNIQUE: Multiple axial images were obtained of the brain. 5 mm sections were acquired. 2.5-mm sections were acquired without injection of intravenous contrast. Reformatted sagittal and coronal images were obtained.,DISCUSSION: No acute intracranial abnormalities appreciated. No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections. No cortical based abnormalities appreciated. The sinuses are clear. No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION: No acute intracranial abnormalities appreciated.,"
} | [
{
"label": " Neurology",
"score": 1
}
] | Argilla | null | null | false | null | c5c1caf4-1412-4294-b9de-cc2d8ef586c3 | null | Default | 2022-12-07T09:37:28.785871 | {
"text_length": 705
} |
PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well. | {
"text": "PREOPERATIVE DIAGNOSIS:, Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS: ,Rule out temporal arteritis.,PROCEDURE:, Bilateral temporal artery biopsy.,ANESTHESIA:, Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:, I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis. I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way. After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery. The temporal artery was identified and was grossly normal on both sides. Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult. The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm. They were sent as separate specimens, right and left labeled. The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond. She tolerated the procedure well."
} | [
{
"label": " Neurology",
"score": 1
}
] | Argilla | null | null | false | null | c5d7bfb4-0fea-494c-b73a-43013de0df20 | null | Default | 2022-12-07T09:37:13.578656 | {
"text_length": 969
} |
REASON FOR CONSULTATION:, Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS: ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital. A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism. A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis. A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct. Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today. He has been on intravenous heparin and hemodialysis is being planned for tomorrow. Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication. He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY: ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son. He has a brother who is healthy. There is no history of tobacco use or alcohol use.,FAMILY HISTORY:, No family history of hypercoagulable condition.,MEDICATIONS: ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope. He denied any hemoptysis. He denied any calf swelling or pain. Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL: He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT: Sclerae anicteric. Conjunctivae normal. Oropharynx normal.,NECK: No adenopathy or thyromegaly. No jugular venous distention.,HEART: Regular.,LUNGS: Bilateral air entry.,ABDOMEN: Obese and benign.,EXTREMITIES: No calf swelling or calf tenderness appreciated.,SKIN: No petechiae or ecchymosis.,NEUROLOGIC: Nonfocal.,LABORATORY FINDINGS:, Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000. Liver profile normal. Thyroid study revealed a TSH of 1.3. Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds. Renal function, BUN 44 and creatinine 5.7. Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1. Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2. Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3. Acute renal failure secondary to embolic right renal infarction.,4. Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play. For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin. In view of worsening renal function, may need temporary hemodialysis until renal function improves. I discussed at length with the patient's wife at the bedside. | {
"text": "REASON FOR CONSULTATION:, Acute deep venous thrombosis, right lower extremity with bilateral pulmonary embolism, on intravenous heparin complicated with acute renal failure for evaluation.,HISTORY OF PRESENTING ILLNESS: ,Briefly, this is a 36-year-old robust Caucasian gentleman with no significant past medical or surgical history, who works as a sales representative, doing a lot of traveling by plane and car and attending several sales shows, developed acute shortness of breath with an episode of syncope this weekend and was brought in by paramedics to Hospital. A V/Q scan revealed multiple pulmonary perfusion defects consistent with high probability pulmonary embolism. A Doppler venous study of the lower extremity also revealed nonocclusive right popliteal vein thrombosis. A CT of the abdomen and pelvis revealed normal-appearing liver, spleen, and pancreas; however, the right kidney appeared smaller compared to left and suggesting possibility of renal infarct. Renal function on admission was within normal range; however, serial renal function showed rapid increase in creatinine to 5 today. He has been on intravenous heparin and hemodialysis is being planned for tomorrow. Reviewing his history, there is no family members with hypercoagulable state or prior history of any thrombotic complication. He denies any recent injury to his lower extremity and in fact denied any calf pain or swelling.,PAST MEDICAL AND SURGICAL HISTORY: ,Unremarkable.,SOCIAL HISTORY: , He is married and has 1 son. He has a brother who is healthy. There is no history of tobacco use or alcohol use.,FAMILY HISTORY:, No family history of hypercoagulable condition.,MEDICATIONS: ,Advil p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS: , Essentially unremarkable except for sudden onset dyspnea on easy exertion complicated with episode of syncope. He denied any hemoptysis. He denied any calf swelling or pain. Lately, he has been traveling and has been sitting behind a desk for a long period of time.,PHYSICAL EXAMINATION:,GENERAL: He is a robust young gentleman, awake, alert, and hemodynamically stable.,HEENT: Sclerae anicteric. Conjunctivae normal. Oropharynx normal.,NECK: No adenopathy or thyromegaly. No jugular venous distention.,HEART: Regular.,LUNGS: Bilateral air entry.,ABDOMEN: Obese and benign.,EXTREMITIES: No calf swelling or calf tenderness appreciated.,SKIN: No petechiae or ecchymosis.,NEUROLOGIC: Nonfocal.,LABORATORY FINDINGS:, Blood count obtained showed a white count of 16.8, hemoglobin 14.8 g percent, hematocrit 44.6%, MCV 94, and platelet count 209,000. Liver profile normal. Thyroid study revealed a TSH of 1.3. Prothrombin time/INR 1.5, partial thromboplastin time 78.6 seconds. Renal function, BUN 44 and creatinine 5.7. Echocardiogram revealed left ventricular hypertrophy with ejection fraction of 65%, no intramural thrombus noted.,IMPRESSION:,1. Bilateral pulmonary embolism, most consistent with emboli from right lower extremity, on intravenous heparin, rule out hereditary hypercoagulable state.,2. Leukocytosis, most likely leukemoid reaction secondary to acute pulmonary embolism/renal infarction, doubt presence of myeloproliferative disorder.,3. Acute renal failure secondary to embolic right renal infarction.,4. Obesity.,PLAN: , From hematologic standpoint, we will await hypercoagulable studies, which have all been sent on admission to see if a hereditary component is at play. For now, we will continue intravenous heparin and subsequent oral anticoagulation with Coumadin. In view of worsening renal function, may need temporary hemodialysis until renal function improves. I discussed at length with the patient's wife at the bedside."
} | [
{
"label": " Hematology - Oncology",
"score": 1
}
] | Argilla | null | null | false | null | c5fcff3d-e7e6-4e07-a98d-5b24a342a120 | null | Default | 2022-12-07T09:37:53.647892 | {
"text_length": 3715
} |
TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL: ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei. He was admitted for a left wound breakdown with drainage. He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit. It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia. The patient understood these risks and wished to proceed. The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic. He was placed in the right lateral decubitus, and all bony prominences were well padded. An axillary roll was placed. A well-padded thigh tourniquet was placed on the left leg. The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement. Left leg was then prepped and draped in usual sterile fashion. The previous five antibiotic spacer beads were removed without difficulty. The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone. The wound actually looked quite good with evidence of purulence or drainage. Skin edges appeared to be viable. Hardware all looked to be intact. At this point, the wound was irrigated with 9 liters of bibiotic solution. A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint. The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure. He was immediately available for any questions during the case.,PLAN:,1. A CAM walker boots.,2. A VAC change on Sunday by the nurse.,3. A flap per Plastic Surgery. | {
"text": "TITLE OF OPERATION:,1. Irrigation and debridement of postoperative wound infection (CPT code 10180).,2. Removal of foreign body, deep (CPT code 28192).,3. Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL: ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei. He was admitted for a left wound breakdown with drainage. He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit. It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap. The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia. The patient understood these risks and wished to proceed. The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic. He was placed in the right lateral decubitus, and all bony prominences were well padded. An axillary roll was placed. A well-padded thigh tourniquet was placed on the left leg. The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement. Left leg was then prepped and draped in usual sterile fashion. The previous five antibiotic spacer beads were removed without difficulty. The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone. The wound actually looked quite good with evidence of purulence or drainage. Skin edges appeared to be viable. Hardware all looked to be intact. At this point, the wound was irrigated with 9 liters of bibiotic solution. A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint. The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure. He was immediately available for any questions during the case.,PLAN:,1. A CAM walker boots.,2. A VAC change on Sunday by the nurse.,3. A flap per Plastic Surgery."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c601a971-e8c1-48ab-a559-5a5821d096c2 | null | Default | 2022-12-07T09:33:48.539935 | {
"text_length": 2480
} |
GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation. | {
"text": "GENERAL: , Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F. Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva. No lesions. Pupils equal, round, reactive to light and accommodation. Irises symmetrical, undilated. Funduscopic exam reveals no hemorrhages or discopathy. Ears, Nose, Mouth, and throat: External ears without lesions. Nares patent. Septum midline. Tympanic membranes without erythema, bulging or retraction. Canals without lesion. Hearing is grossly intact. Lips, teeth, gums, palate without lesion. Posterior oropharynx: No erythema. No tonsillar enlargement, crypt formation or abscess.,NECK: ,Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain.,RESPIRATORY: , Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus.,CARDIOVASCULAR:, Regular rate and rhythm. No murmur, gallops, clicks, heaves or rub. Cardiac palpation within normal limits. Pulses equal at carotid. Femoral and pedal pulses: No peripheral edema.,GASTROINTESTINAL: ,No tenderness or mass. No hepatosplenomegaly. No hernia. Bowel sounds equal times four quadrants. Abdomen is nondistended. No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline. Full range of motion with flexion, extension and sidebending.,SKIN:, Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.,LYMPH:, Cervical lymph nodes. No lymphadenopathy.,NEUROLOGICAL: ,Cranial nerves II-XII grossly intact. DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle. Motor strength 4/4 bilateral upper and lower extremity. Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate. Alert and oriented times three. Memory and mood within normal limits. No delusions, hallucinations. No suicidal or homicidal ideation."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c60a5e75-69df-40bf-99ef-72dc7cbe5cbd | null | Default | 2022-12-07T09:39:40.784068 | {
"text_length": 2327
} |
PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications. | {
"text": "PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications."
} | [
{
"label": " ENT - Otolaryngology",
"score": 1
}
] | Argilla | null | null | false | null | c60d354c-d071-4376-86a5-7ba139fbbc71 | null | Default | 2022-12-07T09:38:50.422481 | {
"text_length": 3928
} |
SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet. | {
"text": "SUBJECTIVE:, His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.,OBJECTIVE:, Height: 6 foot 2 inches. Weight: 204 pounds on 03/07/05. Ideal body weight: 190 pounds, plus or minus ten percent. He is 107 percent standard of midpoint ideal body weight. BMI: 26.189. A 48-year-old male. Lab on 03/15/05: Cholesterol: 251. LDL: 166. VLDL: 17. HDL: 68. Triglycerides: 87. I explained to the patient the dietary guidelines to help improve his lipids. I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight. I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read. I encouraged him to continue as he is doing.,ASSESSMENT:, Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories. His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake. He needs to continue as he is doing. He verbalized understanding and seemed receptive.,PLAN:, The patient plans to recheck his lipids through Dr. XYZ I gave him my phone number and he is to call me if he has any further questions regarding his diet."
} | [
{
"label": " Diets and Nutritions",
"score": 1
}
] | Argilla | null | null | false | null | c62edad6-3e73-430f-8d2b-a7a71ccfdd84 | null | Default | 2022-12-07T09:39:16.937110 | {
"text_length": 1839
} |
DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease., | {
"text": "DIAGNOSIS: ,Shortness of breath. Fatigue and weakness. Hypertension. Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,"
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c63bf1ee-effc-4ee3-b1f2-d4f40b179d34 | null | Default | 2022-12-07T09:35:12.696465 | {
"text_length": 144
} |
PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:, Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. Vaginal delivery was uneventful with a normal perinatal course. Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years). He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. Mom reports that he has several friends, but she is concerned about the time required for the wrestling team. Patient is in 8th grade this year and an A/B student. Both siblings are healthy. His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications. Mom is healthy and has asthma.,PAST MEDICAL HISTORY: ,Patient has been seen in the clinic yearly for well child exams. He has had no major illnesses or hospitalizations. He had one emergency room visit 2 years ago for a knee laceration. Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn. Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food. He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days. He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. Mom or his sister cooks supper in the evening. The family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his Mom. He says he eats "a lot" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight: Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). He is following the growth pattern he established in infancy.,Vital signs: BP 110/60, T 99.2, HR 70, R 16.,General: Alert, cooperative but a bit shy.,Neuro: DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact. He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT: Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal. TMs deep red, dull, landmarks obscured, full bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs: CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac: S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen: Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. Bowel sounds active in all quadrants. No hepatosplenomegaly or tenderness. No CVA tenderness.,Musculoskeletal: Full range of motion, all extremities. Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital: Normal male, Tanner stage 4. Rectal exam - small amount of soft stool, no fissures or masses.,LABS: ,Stool negative for blood and H. pylori antigen. Normal CBC and urinalysis. A barium swallow and upper GI was scheduled for the following week. It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE., There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely. Trauma. Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD., The history of "heartburn" relieved by his father's medication was striking. The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:, Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks. At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. A 6-month follow up appointment was scheduled. | {
"text": "PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain. He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS: ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team. Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms. Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:, Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks. Vaginal delivery was uneventful with a normal perinatal course. Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months. His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years). He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team. Mom reports that he has several friends, but she is concerned about the time required for the wrestling team. Patient is in 8th grade this year and an A/B student. Both siblings are healthy. His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications. Mom is healthy and has asthma.,PAST MEDICAL HISTORY: ,Patient has been seen in the clinic yearly for well child exams. He has had no major illnesses or hospitalizations. He had one emergency room visit 2 years ago for a knee laceration. Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections. He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems. Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn. Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food. He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days. He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch. Mom or his sister cooks supper in the evening. The family goes out to eat once or twice a week and he only gets \"fast food\" once or twice a week according to his Mom. He says he eats \"a lot\" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight: Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile). He is following the growth pattern he established in infancy.,Vital signs: BP 110/60, T 99.2, HR 70, R 16.,General: Alert, cooperative but a bit shy.,Neuro: DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact. He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT: Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal. TMs deep red, dull, landmarks obscured, full bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs: CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac: S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen: Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat. Bowel sounds active in all quadrants. No hepatosplenomegaly or tenderness. No CVA tenderness.,Musculoskeletal: Full range of motion, all extremities. Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital: Normal male, Tanner stage 4. Rectal exam - small amount of soft stool, no fissures or masses.,LABS: ,Stool negative for blood and H. pylori antigen. Normal CBC and urinalysis. A barium swallow and upper GI was scheduled for the following week. It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case. It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment). It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE., There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely. Trauma. Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD., The history of \"heartburn\" relieved by his father's medication was striking. The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:, Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks. Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it. The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication. He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks. At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication. A 6-month follow up appointment was scheduled."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c659d036-437b-4cdb-ae8c-8d0bb0a5f0f1 | null | Default | 2022-12-07T09:40:02.913665 | {
"text_length": 6309
} |
ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term "anatomic" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated. The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:, The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained. On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:, None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1. Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only. In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe. The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2. Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3. At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4. ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1. There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2. There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3. On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4. There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5. On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6. On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length. | {
"text": "ANATOMICAL SUMMARY,1. Sharp force wound of neck, left side, with transection of left internal jugular vein.,2. Multiple stab wounds of chest, abdomen, and left thigh: Penetrating stab wounds of chest and abdomen with right hemothorax and hemoperitoneum.,3. Multiple incised wounds of scalp, face, neck, chest and left hand (defense wound).,4. Multiple abrasions upper extremities and hands (defense wounds).,NOTES AND PROCEDURES,1. The body is described in the Standard Anatomical Position. Reference is to this position only.,2. Where necessary, injuries are numbered for reference. This is arbitrary and does not correspond to any order in which they may have been incurred. All the injuries are antemortem, unless otherwise specified.,3. The term \"anatomic\" is used as a specification to indicate correspondence with the description as set forth in the textbooks of Gross Anatomy. It denotes freedom from significant, visible or morbid alteration.,EXTERNAL EXAMINATION:, The body is that of a well developed, well nourished Caucasian male stated to be 25 years old. The body weighs 171 pounds, measuring 69 inches from crown to sole. The hair on the scalp is brown and straight. The irides appear hazel with the pupils fixed and dilated. The sclerae and conjunctive are unremarkable, with no evidence of petechial hemorrhages on either. Both upper and lower teeth are natural, and there are no injuries of the gums, cheeks, or lips.,There is a picture-type tattoo on the lateral aspect of the left upper arm. There are no deformities, old surgical scars or amputations.,Rigor mortis is fixed.,The body appears to the Examiner as stated above. Identification is by toe tag and the autopsy is not material to identification. The body is not embalmed.,The head is normocephalic, and there is extensive evidence of external traumatic injury, to be described below. Otherwise, the eyes, nose and mouth are not remarkable. The neck shows sharp force injuries to be described below. The front of the chest and abdomen likewise show injuries to be described below. The genitalia are that of an adult male, with the penis circumcised, and no evidence of injury.,Examination of the posterior surface of the trunk reveals no antemortem traumatic injuries.,Refer to available photographs and diagrams and to the specific documentation of the autopsy protocol.,CLOTHING:, The clothes were examined both before and after removal from the body.,The decedent was wearing a long-sleeved type of shirt/sweater; it was extensively bloodstained.,On the front, lower right side, there was a 1 1/2 inch long slit-like tear. Also on the lower right sleeve there was a 1 inch slit-like tear. On the back there was a 1/2 inch slit-like tear on the right lower side.,Decedent was wearing a pair of Levi jeans bloodstained. On the outside of the left hip region there was a 1-1/2 inch long slit-like tear. The decedent also was wearing 2 canvas type boots and 2 sweat socks.,EVIDENCE OF THERAPEUTIC INTERVENTION:, None.,EVIDENCE OF INJURY,SHARP FORCE INJURIES OF NECK,1. Sharp force injury of neck, left side, transecting left internal jugular vein. This sharp force injury is complex, and appears to be a combination of a stabbing and cutting wound. It begins on the left side of the neck, at the level of the midlarynx, over the left sternocleidomastoid muscle; it is gaping, measuring 3 inches in length with smooth edges. It tapers superiorly to 1 inch in length cut skin. Dissection discloses that the wound path is through the skin, the subcutaneous tissue, and the sternocleidomastoid muscle with hemorrhage along the wound path and transection of the left internal jugular vein, with dark red-purple hemorrhage in the adjacent subcutaneous tissue and fascia. The direction of the pathway is upward and slightly front to back for a distance of approximately 4 inches where it exits, post-auricular, in a 2 inch in length gaping stab/incised wound which has undulating or wavy borders, but not serrated. Intersecting the wound at right angle superior inferior is a 2 inch in length interrupted superficial, linear incised wound involving only the skin. Also, intervening between the 2 gaping stab-incised wounds is a horizontally oriented 3-1/2 inch in length interrupted superficial, linear incised wound of the skin only. In addition, there is a 1/2 inch long, linear-triangular in size wound of the inferior portion of the left earlobe. The direction of the sharp force injury is upward (rostral), and slightly front to back with no significant angulation or deviation. The total length of the wound path is approximately 4 inches. However, there is a 3/4 inch in length, linear, cutting or incised wound of the top or superior aspect of the pinna of the left ear; a straight metallic probe placed through the major sharp force injury shows that the injury of the superior part of the ear can be aligned with the straight metallic rod, suggesting that the 3 injuries are related; in this instance the total length of the wound path is approximately 6 inches. Also, in the left postauricular region, transversely oriented, extending from the auricular attachment laterally to the scalp is a 1-1/8 inch in length linear superficial incised skin wound.,OPINION: , This sharp force injury of the neck is fatal, associated with transection of the left internal jugular vein.,2. Sharp force wound of the right side of neck. This is a complex injury, appearing to be a combination stabbing and cutting wound. The initial wound is present on the right side of the neck, over the sternocleidomastoid muscle, 3 inches directly below the right external auditory canal. It is diagonally oriented, and after approximation of the edges measures 5/8 inch in length; there is a pointed or tapered end inferiorly and a split or forked end superiorly approximately 1/16 inch in maximal width. Subsequent autopsy shows that the wound path is through the skin and subcutaneous tissue, without penetration of injury of a major,artery or vein; the direction is front to back and upward for a total wound path length of 2 inches and the wound exits on the right side of the back of the neck, posterior to the right sternocleidomastoid muscle where a 2 inch long gaping incised/stab wound is evident on the skin; both ends are tapered; superiorly there is a 1 inch long superficial incised wounds extension on the skin to the back of the head; inferiorly there is a 2 inch long incised superficial skin extension, extending inferiorly towards the back of the neck. There is fresh hemorrhage and bruising along the wound path; the direction, as stated, is upward and slightly front to back.,OPINION: ,This is a nonfatal sharp force injury, with no injury or major artery or vein.,3. At the level of the superior border of the larynx there is a transversely oriented, superficial incised wound of the neck, extending from 3 inches to the left of the anterior midline; it is 3 inches in length and involves the skin only; a small amount of cutaneous hemorrhage is evident.,OPINION:, This is a nonfatal superficial incised wound.,4. ImmediateLY inferior and adjacent to incised wound #3 is a transversely oriented, superficial incised wound involving the skin and subcutaneous tissue; there is a small amount of dermal hemorrhage.,OPINION:, This is a nonfatal superficial incised wound.,SHARP FORCE INJURIES OF FACE,1. There is a stab wound, involving the right earlobe; it is vertically oriented, and after approximation of the edges measures 1 inch in length with forked or split ends superiorly and inferiorly approximately 1/16 inch in total width both superior and inferior. Subsequent dissection discloses that the wound path is from right to left, in the horizontal plane for approximately 1-1/4 inches; there is fresh hemorrhage along the wound path; the wound path terminates in the left temporal bone and does not penetrate the cranial cavity.,OPINION:, This is a nonfatal stab wound.,2. There is a group of 5 superficial incised or cutting wounds on the right side of the face, involving the right cheek and the right side of the jaw. They are varied in orientation both diagonal and horizontal; the smallest is 1/4 inch in length; the largest 5/8 inch in length. They are superficial, involving the skin only, associated with a small amount of cutaneous hemorrhage.,3. On the back of the neck, right side, posterior to the ear and posterior border of the right sternocleidomastoid muscle there is vertically oriented superficial incised skin wound, measuring 3/4 inch in length.,4. There are numerous superficial incised wounds or cuts, varied in orientation, involving the skin of the right cheek, intersection and mingled with the various superficial incised wounds described above. The longest is a 3 inch long diagonally oriented superficial incised wound extending from the right side of the forehead to the cheek; various other superficial wound vary from 1/2 to 1 inch.,5. On the right side of the cheek, adjacent to the ramus of the mandible, right, there is a 1-1/2 x 3/4 inch superficial nonpatterned red-brown abrasion with irregular border, extending superiorly towards the angle of the jaw where there are poorly defined and circumscribed abrasions adjacent to the superficial cuts or abrasions described above. It should be noted that the 5th superficial incised wound of the right side of the mandible which measures 5/8 inch in length is tapered on the posterior aspect and forked on the anterior aspect where it has a width of 1/32 inch.,6. On the left ear, there is a superficial incised wound measuring 1/4 inch, adjacent to the posterior border of the pinna. Just below this on the inferior pinna, extending to the earlobe, there is an interrupted superficial linear abrasion measuring 1 inch in length."
} | [
{
"label": " Autopsy",
"score": 1
}
] | Argilla | null | null | false | null | c65fdece-eea5-4ee7-b4d3-f6881f83db4b | null | Default | 2022-12-07T09:40:59.789882 | {
"text_length": 9809
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INTRODUCTION: , The opinions expressed in this report are those of the physician. The opinions do not reflect the opinions of Evergreen Medical Panel, Inc. The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I). The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager. The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:, This patient was injured on November 20, 2008. He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. The patient said he primarily landed on the left side. After the accident he states that he was generally stun and someone at the institute advised him to be evaluated. He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital. At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan. The patient describes that he had a brain CT and a dark spot was found. It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma. Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005. The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ. She ordered an MRI of his neck. Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS: ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses: The patient had a diagnosis in 2005 of an acoustic neuroma. It was benign, but treated neurosurgically. In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations: He has a history of an old mastoidectomy. He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications: The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco: He does not smoke cigarettes.,Alcohol: He drinks about five beers a week.,FAMILY HISTORY:, His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents.,Education: The patient has bachelor's degree.,Military History: He served six years in the army and received an honorable discharge.,Work History: He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008. He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain. He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended. He has a history of an old mastoidectomy. He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008. There is no clearcut history that he had lost consciousness. He has a past history of removal of an acoustic neuroma in 2005 as noted. A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma. Some symptoms of loss of balance and confusion were noted. She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008. Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties. It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard. There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma. He continued to have chiropractic adjustments. He was seen back at Prompt Care on January 8, 2009. Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain. He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate. Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ. He felt that this was hyperextension cervical injury. It might take a period of time to recover. He mentioned that the patient might have a slight ulnar neuropathy. He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination: He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance. Overall the patient is a seemingly good historian. There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly. These are secondary to drawing for the skull markers. There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma. This was well healed. The patient can perform a toe-heel gait without difficulty. One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering. The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had. The patient has a full range of motion in both of his shoulders. The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees. There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest. He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction. There is slight tenderness on palpating over the right cervical musculature. There is no evidence of any cervical or lumbar muscle spasms. Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis. Knee jerks are 2+ and ankle jerks are 1+. Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally. The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally. Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left. Testing of muscle strength in the upper and lower extremities is normal. The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally. The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally. The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm. Pressure on the vertex of the head does not bother the patient. Axial loading is negative. As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space. The hip joints are normal. Views of his thoracic spine are normal. Cervical x-rays are in the file. These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc. There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:, The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan. The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008. Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine. He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270. His industrial case should be closed and there is, as indicated, no basis for any disability award. | {
"text": "INTRODUCTION: , The opinions expressed in this report are those of the physician. The opinions do not reflect the opinions of Evergreen Medical Panel, Inc. The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I). The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager. The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:, This patient was injured on November 20, 2008. He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. The patient said he primarily landed on the left side. After the accident he states that he was generally stun and someone at the institute advised him to be evaluated. He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital. At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan. The patient describes that he had a brain CT and a dark spot was found. It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma. Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005. The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ. She ordered an MRI of his neck. Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS: ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses: The patient had a diagnosis in 2005 of an acoustic neuroma. It was benign, but treated neurosurgically. In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations: He has a history of an old mastoidectomy. He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications: The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco: He does not smoke cigarettes.,Alcohol: He drinks about five beers a week.,FAMILY HISTORY:, His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents.,Education: The patient has bachelor's degree.,Military History: He served six years in the army and received an honorable discharge.,Work History: He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008. He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain. He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended. He has a history of an old mastoidectomy. He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008. There is no clearcut history that he had lost consciousness. He has a past history of removal of an acoustic neuroma in 2005 as noted. A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma. Some symptoms of loss of balance and confusion were noted. She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008. Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties. It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard. There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma. He continued to have chiropractic adjustments. He was seen back at Prompt Care on January 8, 2009. Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain. He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate. Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ. He felt that this was hyperextension cervical injury. It might take a period of time to recover. He mentioned that the patient might have a slight ulnar neuropathy. He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination: He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance. Overall the patient is a seemingly good historian. There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly. These are secondary to drawing for the skull markers. There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma. This was well healed. The patient can perform a toe-heel gait without difficulty. One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering. The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had. The patient has a full range of motion in both of his shoulders. The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees. There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest. He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction. There is slight tenderness on palpating over the right cervical musculature. There is no evidence of any cervical or lumbar muscle spasms. Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis. Knee jerks are 2+ and ankle jerks are 1+. Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally. The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally. Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left. Testing of muscle strength in the upper and lower extremities is normal. The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally. The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally. The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm. Pressure on the vertex of the head does not bother the patient. Axial loading is negative. As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space. The hip joints are normal. Views of his thoracic spine are normal. Cervical x-rays are in the file. These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc. There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:, The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan. The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008. Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine. He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270. His industrial case should be closed and there is, as indicated, no basis for any disability award."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c6629b4c-ea01-4067-b928-8e8e7e819f2b | null | Default | 2022-12-07T09:36:17.118538 | {
"text_length": 11506
} |
PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:, Postoperative hemorrhage.,SURGICAL PROCEDURE: ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA: ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty. However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY: ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage. A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized. There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated. There was no other bleeding noted. The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined. There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery. No other bleeding was noted and the patient was recovered from general anesthetic. She was extubated and left the operating room in good condition to postoperative recovery room area. Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis. | {
"text": "PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:, Postoperative hemorrhage.,SURGICAL PROCEDURE: ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA: ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty. However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY: ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage. A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized. There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated. There was no other bleeding noted. The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined. There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery. No other bleeding was noted and the patient was recovered from general anesthetic. She was extubated and left the operating room in good condition to postoperative recovery room area. Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c66c4591-ded2-4753-b068-5804da9c7b93 | null | Default | 2022-12-07T09:34:15.232097 | {
"text_length": 2045
} |
PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation.,PROCEDURE PERFORMED:, Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces. Apgars were 9 at 1 minute and 9 at 5 minutes. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation. The patient progressed to 8 cm, at which time, Pitocin was started. She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm. A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where epidural anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction. Clear fluid was noted. The infant was subsequently delivered atraumatically. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform. Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic suture. Hemostasis was visualized. The uterus was returned to the abdomen.,The pelvis was copiously irrigated. The uterine incision was reexamined and was noted to be hemostatic. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition. | {
"text": "PREOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation. ,POSTOPERATIVE DIAGNOSES:,1. Intrauterine pregnancy at term.,2. Arrest of dilation.,PROCEDURE PERFORMED:, Primary low-transverse cesarean section.,ANESTHESIA: , Epidural.,ESTIMATED BLOOD LOSS: , 1000 mL.,COMPLICATIONS: , None.,FINDINGS: ,Female infant in cephalic presentation, OP position, weight 9 pounds 8 ounces. Apgars were 9 at 1 minute and 9 at 5 minutes. Normal uterus, tubes, and ovaries were noted.,INDICATIONS: ,The patient is a 20-year-old gravida 1, para 0 female, who presented to labor and delivery in early active labor at 40 and 6/7 weeks gestation. The patient progressed to 8 cm, at which time, Pitocin was started. She subsequently progressed to 9 cm, but despite adequate contractions, arrested dilation at 9 cm. A decision was made to proceed with a primary low transverse cesarean section.,The procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and possible need for further surgery. Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE: ,The patient was taken to the operating room where epidural anesthesia was found to be adequate. The patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a left-ward tilt. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the Bovie. The fascia was incised in the midline and extended laterally using Mayo scissors. Kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. Attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with Kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using Mayo scissors. The rectus muscles were dissected in the midline.,The peritoneum was bluntly dissected, entered, and extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was inserted. The vesicouterine peritoneum was identified with pickups and entered sharply using Metzenbaum scissors. This incision was extended laterally and the bladder flap was created digitally. The bladder blade was reinserted. The lower uterine segment was incised in a transverse fashion using the scalpel and extended using manual traction. Clear fluid was noted. The infant was subsequently delivered atraumatically. The nose and mouth were bulb suctioned. The cord was clamped and cut. The infant was subsequently handed to the awaiting nursery nurse. Next, cord blood was obtained per the patient's request for cord blood donation, which took several minutes to perform. Subsequent to the collection of this blood, the placenta was removed spontaneously intact with a 3-vessel cord noted. The uterus was exteriorized and cleared of all clots and debris. The uterine incision was repaired in 2 layers using 0 chromic suture. Hemostasis was visualized. The uterus was returned to the abdomen.,The pelvis was copiously irrigated. The uterine incision was reexamined and was noted to be hemostatic. The rectus muscles were reapproximated in the midline using 3-0 Vicryl. The fascia was closed with 0 Vicryl, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. Sponge, lap, and instrument counts were correct x2. The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition."
} | [
{
"label": " Obstetrics / Gynecology",
"score": 1
}
] | Argilla | null | null | false | null | c6776ebf-de41-4f9b-96cc-6db3d4b84e3c | null | Default | 2022-12-07T09:36:54.280678 | {
"text_length": 3713
} |
PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications. | {
"text": "PREOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1. Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2. Tonsillitis with hypertrophy.,3. Edema to the uvula and soft palate.,OPERATION PERFORMED,1. Nasal septoplasty.,2. Bilateral submucous resection of the inferior turbinates.,3. Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction. He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis. He also has developed tremendous edema to his posterior palate and uvula, which is causing choking. Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION: ,The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL. Afrin-soaked pledgets were placed in the nasal cavity bilaterally. The face was prepped with pHisoHex and draped in a sterile fashion. A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator. The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel. Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion. The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope. Hemostasis was acquired by using suction electrocautery. The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture. The table was then turned. A shoulder roll placed under the shoulders and the face was draped in a clean fashion. A McIvor mouth gag was applied. The tongue was retracted and the McIvor was gently suspended from the Mayo stand. The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion. The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery. The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion. The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery. The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion. Copious saline irrigation of the oral cavity was then performed. There was no further identifiable bleeding at the termination of the procedure. The estimated blood loss was less than 10 mL. The patient was extubated in the operating room, brought to the recovery room in satisfactory condition. There were no intraoperative complications."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c67e3440-de54-4e85-98e3-71e63092081d | null | Default | 2022-12-07T09:33:30.327121 | {
"text_length": 3928
} |
PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear "S"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition. | {
"text": "PREOPERATIVE DIAGNOSIS: , Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body in the right foot.,PROCEDURE PERFORMED:, Excision of foreign body, right foot and surrounding tissue.,ANESTHESIA: , TIVA and local.,HISTORY:, This 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. The patient works in the Electronics/Robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. The wire entered his foot. His family physician attempted to remove the wire, but it only became deeper in the foot. The wound eventually healed, but a scar tissue was formed. The patient has had constant pain with ambulation intermittently since the incident occurred. He desires attempted surgical removal of the wire. The risks and benefits of the procedure have been explained to the patient in detail by Dr. X. The consent is available on the chart for review.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,A pneumatic ankle tourniquet was applied about the right ankle over copious amounts of Webril for the patient's protection. After adequate IV sedation was administered by the Department of Anesthesia, a total of 12 cc of 0.5% Marcaine plain was used to administer an ankle block. Next, the foot was prepped and draped in the usual aseptic fashion. An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg. The foot was lowered into the operative field and the sterile stockinet was reflected. Attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. This was the origin and entry point of the previous puncture wound from the wire. This cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. Next, the Xi-scan was draped and brought into the operating room. A #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. Next, a #10 blade was used to make approximately a 3 cm curvilinear \"S\"-shaped incision. Next, the #15 blade was used to carry the incision through the subcutaneous tissue. The medial and lateral margins of the incision were undermined. Due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. Therefore, they were removed. Once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. A second hemostat was used to clamp the wire. A #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. The wire quickly came into visualization. It measured approximately 4 mm in length and was approximately 1 mm in diameter. The wire was green colored and metallic in nature. It was removed with the hemostat and passed off as a specimen to be sent to Pathology for identification. The wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. Next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. Next, a #3-0 Vicryl was used to throw two simple interrupted deep sutures to remove the dead space. Next, #4-0 Ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. The standard postoperative dressing consisting of saline-soaked Owen silk, 4x4s, Kling, Kerlix, and Coban were applied. The pneumatic ankle tourniquet was released. There was immediate hyperemic flush to the digits noted. The patient's anesthesia was reversed. He tolerated the above anesthesia and procedure without complications. The patient was transported via cart to the Postanesthesia Care Unit.,Vital signs were stable and vascular status was intact to the right foot. He was given OrthoWedge shoe. Ice was applied behind the knee and his right lower extremity was elevated on to pillows. He was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. He is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. He is to follow up with Dr. X on 08/22/2003 and was given emergency contact number to call if problems arise. He was given a prescription for Tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as Celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. He was given crutches. He was discharged in stable condition."
} | [
{
"label": " Podiatry",
"score": 1
}
] | Argilla | null | null | false | null | c68195a6-2814-430f-b3ce-10a2b9b5f538 | null | Default | 2022-12-07T09:35:41.771991 | {
"text_length": 5138
} |
PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed. | {
"text": "PREOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1. Bunion left foot.,2. Hammertoe, left second toe.,PROCEDURE PERFORMED:,1. Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2. Arthroplasty left second toe.,HISTORY: ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area. The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff. After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot. The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table. The stockinette was reflected. The foot was cleansed with wet and dry sponge. Attention was then directed to the first metatarsophalangeal joint of the left foot. An incision was created over this area approximately 6 cm in length. The incision was deepened with a #15 blade. All vessels encountered were ligated for hemostasis. The skin and subcutaneous tissue was then dissected from the capsule. Care was taken to preserve the neurovascular bundle. Dorsal linear capsular incision was then created. The capsule was then reflected from the head of the first metatarsal. Attention was then directed to the first interspace where a lateral release was performed. A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. A lateral capsulotomy was performed. Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. The incision was then extended proximally with further dissection down to the level of the bone. Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy. A standard SCARF osteotomy was then performed. The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire. A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted. A second 3.0 x 14 mm screw was also inserted with tight compression noted. The remaining prominent medial eminence medially was then resected with a sagittal saw. Reciprocating rasps were then used to smooth any sharp bony edges. The temporary fixation wires were then removed. The screws were again checked for tightness, which was noted. Attention was directed to the medial capsule where a medial capsulorrhaphy was performed. A straight stat was used to assist in removing a portion of the capsule. The capsule was then reapproximated with #2-0 Vicryl medially. Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion. The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl. The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe. A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. An incision was made on either side of the extensor digitorum longus tendon. A curved mosquito stat was then used to reflex the tendon laterally. The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. A sagittal saw was then used to resect the head of the proximal head. The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. The extensor digitorum longus tendon was inspected and noted to be intact. Any sharp edges were then smoothed with reciprocating rasp. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon. Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban. Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact to the left foot. The patient is to follow up with Dr. X in his clinic as directed."
} | [
{
"label": " Podiatry",
"score": 1
}
] | Argilla | null | null | false | null | c68bd38f-39e3-4313-8b8a-aa1ffde687f2 | null | Default | 2022-12-07T09:35:43.122691 | {
"text_length": 5263
} |
REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.,IMPRESSION:,1. Good exercise tolerance.,2. Adequate heart rate and blood pressure response.,3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease., | {
"text": "REASON FOR EXAMINATION:, Abnormal EKG.,FINDINGS: , The patient was exercised according to standard Bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. Peak blood pressure was 132/60. The patient did not experience any chest discomfort during stress or recovery. The test was terminated due to leg fatigue and achieving target heart rate.,Electrocardiogram during stress and recovery did not reveal an additional 1 mm of ST depression compared to the baseline electrocardiogram. Technetium was injected at 5 minutes into stress.,IMPRESSION:,1. Good exercise tolerance.,2. Adequate heart rate and blood pressure response.,3. This maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,"
} | [
{
"label": " Cardiovascular / Pulmonary",
"score": 1
}
] | Argilla | null | null | false | null | c68f55f1-0af0-43ea-a8ba-df76e848267c | null | Default | 2022-12-07T09:40:21.419174 | {
"text_length": 860
} |
PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition. | {
"text": "PROCEDURE:, Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:, Local sedation.,VITAL SIGNS:, See nurse's records.,COMPLICATIONS:, None.,DETAILS OF PROCEDURE:, INT was placed. The patient was in the sitting position and the back was prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between __________. A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted. After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected. Neosporin and a band-aid were applied over the puncture site. The patient was then placed in supine position. The patient was discharged to the recovery room in stable condition."
} | [
{
"label": " Pain Management",
"score": 1
}
] | Argilla | null | null | false | null | c698cc3b-9b86-425b-ae5d-c5f1cc9b8e53 | null | Default | 2022-12-07T09:35:54.542285 | {
"text_length": 805
} |
SUBJECTIVE:, | {
"text": "SUBJECTIVE:,"
} | [
{
"label": " SOAP / Chart / Progress Notes",
"score": 1
}
] | Argilla | null | null | false | null | c69df3d4-fa9b-4902-85e0-f5255531a0cf | null | Default | 2022-12-07T09:34:55.832280 | {
"text_length": 12
} |
SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:, She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight. | {
"text": "SUBJECTIVE:, The patient has recently had an admission for pneumonia with positive blood count. She was treated with IV antibiotics and p.o. antibiotics; she improved on that. She was at home and doing quite well for approximately 10 to 12 days when she came to the ER with a temperature of 102. She was found to have strep. She was treated with penicillin and sent home. She returned about 8 o'clock after vomiting and a probable seizure. Temperature was 104.5; she was lethargic after that. She had an LP, which was unremarkable. She had blood cultures, which have not grown anything. The CSF has not grown anything at this point.,PHYSICAL EXAMINATION:, She is alert, recovering from anesthesia. Head, eyes, ears, nose and throat are unremarkable. Chest is clear to auscultation and percussion. Abdomen is soft. Extremities are unremarkable.,LAB STUDIES: , White count in the emergency room was 9.8 with a slight shift. CSF glucose was 68, protein was 16, and there were no cells. The Gram-stain was unremarkable.,ASSESSMENT: , I feel that this patient has a febrile seizure.,PLAN: , My plan is to readmit the patient to control her temperature and assess her white count. I am going to observe her overnight."
} | [
{
"label": " General Medicine",
"score": 1
}
] | Argilla | null | null | false | null | c6b3ac39-8f34-4528-bef9-52a70189b2ff | null | Default | 2022-12-07T09:38:07.444552 | {
"text_length": 1229
} |
PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone. Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:, minimal. | {
"text": "PRE AND POSTOPERATIVE DIAGNOSIS:, Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone. Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:, minimal."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c6b8af45-5eea-42c2-8d39-df9d44cf3e8d | null | Default | 2022-12-07T09:33:51.190911 | {
"text_length": 3271
} |
CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a "rubber-band" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a "boomerang" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly "too high" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild "concussion" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia. | {
"text": "CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a \"rubber-band\" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a \"boomerang\" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly \"too high\" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild \"concussion\" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia."
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c6bae764-ba49-4fda-9ca1-384b18878e65 | null | Default | 2022-12-07T09:35:17.159585 | {
"text_length": 5412
} |
PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE: ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding. | {
"text": "PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:, Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE: ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage. His condition is felt to be critical. In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy. I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic. Subsequently a 1 cm incision was made over Kocher's point. Hemostasis was obtained. Then a twist drill was made over this area. Bones strips were irrigated away. The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed. This was then passed into the left lateral ventricle on the first pass. Excellent aggressive very bloody CSF under pressure was noted. This stopped, slowed, and some clots were noted. This was irrigated and then CSF continued. Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well. The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding."
} | [
{
"label": " Neurosurgery",
"score": 1
}
] | Argilla | null | null | false | null | c6cc63f4-c8f6-4361-ba7d-08f7f5528f30 | null | Default | 2022-12-07T09:37:02.936809 | {
"text_length": 1682
} |
REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation. | {
"text": "REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had \"nervous breakdowns\" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c6f026dd-899f-49c4-9344-dbcb62da4e78 | null | Default | 2022-12-07T09:39:34.645909 | {
"text_length": 3786
} |
PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition. | {
"text": "PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c6f7c8de-1c0f-425c-8afd-86bf9daa0ea7 | null | Default | 2022-12-07T09:33:09.597161 | {
"text_length": 1641
} |
INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:, | {
"text": "INDICATIONS: ,Chest pain.,STRESS TECHNIQUE:,"
} | [
{
"label": " Radiology",
"score": 1
}
] | Argilla | null | null | false | null | c7057cf9-6c31-4689-984c-a7357c58a634 | null | Default | 2022-12-07T09:35:10.010153 | {
"text_length": 45
} |
HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:, History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:, PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,IMPRESSION: ,1. Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2. Renal failure requiring dialysis.,3. Hypertension.,RECOMMENDATIONS: ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow. If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions. At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy. Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions. An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen. | {
"text": "HISTORY: , A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.,PAST MEDICAL HISTORY:, History of urticaria, history of renal failure with hypertension possible source of renal failure, history of dialysis times 2 years and a history of hypertension.,PAST SURGICAL HISTORY:, PermCath insertion times 3 and peritoneal dialysis.,FAMILY HISTORY: , Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.,CURRENT MEDICATIONS: , Atenolol, sodium bicarbonate, Lovaza, and Dialyvite.,ALLERGIES: , Heparin causing thrombocytopenia.,SOCIAL HISTORY: , Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Age 34, blood pressure 128/78, pulse 70, temperature is 97.8, weight is 207 pounds, and height is 5 feet 7 inches.,GENERAL: The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD: Normocephalic. No masses or lesions noted.,FACE: No facial tenderness or asymmetry noted.,EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally.,EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits.,NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted.,THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted.,NECK: The neck is supple with no adenopathy or masses palpated. The trachea is midline. The thyroid gland is of normal size with no nodules.,NEUROLOGIC: Facial nerve is intact bilaterally. The remaining cranial nerves are intact without focal deficit.,LUNGS: Clear to auscultation bilaterally. No wheeze noted.,HEART: Regular rate and rhythm. No murmur noted.,IMPRESSION: ,1. Acute allergic reaction, etiology uncertain, however, suspicious for Keflex.,2. Renal failure requiring dialysis.,3. Hypertension.,RECOMMENDATIONS: ,RAST allergy testing for both food and environmental allergies was performed, and we will get the results back to the patient with further recommendations to follow. If there is any specific food or inhalant allergen that is found to be quite high on the sensitivity scale, we would probably recommend the patient to avoid the offending agent to hold off on any further reactions. At this point, I would recommend the patient stopping any further use of cephalosporin antibiotics, which may be the cause of his allergic reaction, and I would consider this an allergy. Being on atenolol, the patient has a more difficult time treating acute anaphylaxis, but I do think this is medically necessary at this time and hopefully we can find specific causes for his allergic reactions. An EpiPen was also prescribed in the event of acute angioedema or allergic reaction or sensation of impending allergic reaction and he is aware he needs to proceed directly to the emergency room for further evaluation and treatment recommendations after administration of an EpiPen."
} | [
{
"label": " Consult - History and Phy.",
"score": 1
}
] | Argilla | null | null | false | null | c7093b12-28f3-47b5-9bec-3896b5d574da | null | Default | 2022-12-07T09:40:17.842270 | {
"text_length": 4379
} |
Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed. | {
"text": "Chief Complaint:, Abdominal pain, nausea, vomiting, fever, altered mental status.,History of Present Illness:, 55 yo WM with reactive airways disease, allergic rhinitis who was in his usual state of health until he underwent a dental extraction with administration of cephalexin 1 week prior to admission. Approximately one day after the dental procedure, he began having nausea, and abdominal pain along with fatigue. The abdominal pain was described as pressure-like and was located in the epigastrium and periumbilical regions. He initially attributed the symptoms to a side effect of the antibiotic he was taking. However, with worsening of his symptoms, he presented to the ER 5 days after dental extraction.,At that time his vitals were T 99.9 ° HR 115 RR 18 BP 182/101. His exam was notable for mild tenderness in the central abdomen. Laboratory evaluation was notable for WBC 15.6, Hgb 13.1, Plt 189, 16% bands, 68% PMNs. Na 127, K4.7, Cl 88, CO2 29, BUN 19, Cr 1.5, Glucose 155, Ca 9.6, alk phos 125, t bili 0.7, ALT 29, nl amylase and lipase. UA with 100 protein, lg blood, 53 RBC, 2 WBC. Plain films done at that time revealed dilation of small bowel loops in mid-abdomen up to 3.5cm in diameter, thought to be most consistent with a paralytic ileus. The patient was discharged home with diagnosis of medication-induced gastroenteritis vs. UTI. He was instructed to stop his current antibiotic but start Levaquin, and he was given Vicodin, and phenergan for symptomatic relief.,Over the next 2 days, the patient began having fevers, non-bloody emesis, diarrhea, and confusion in addition to his persistent nausea, and abdominal pain. On the night of presentation, the patient was found by a cousin in his bathroom lethargic and disoriented. EMS was called and patient was taken to the ER. In the ER, the pt was diaphoretic, unable to answer questions appropriately, hypotensive, and febrile, with some response of bp to multiple IVF boluses (4L). He received acetaminophen, and ceftriaxone 2g IV after blood cultures were obtained and an LP was performed in the ER. He was then admitted to the ICU for further evaluation and management.,Past Medical History:,Asthma,Allergic Rhinitis,Medications:,loratadine,beclomethasone nasal,fluticasone/salmeterol inhaled,Montelukast,cephalexin,hydrocodone,Allergies:, PCN, but has tolerated cephalosporins in the past.,Social History:, No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.,Family History:, HTN, father with SLE, uncle with Addison’s Disease.,Physical Exam:,T 102.9 ° HR 145 RR 22 BP 99/50 98% on room air, (orthostatics were not performed due to patient’s mental status),I/O: minimal urine output after Foley insertion,Gen: lethargic, mild tachypnea,HEENT: no evidence of trauma, sclerae anicteric, pupils are equal round and reactive to light, oropharynx clear, MM dry.,Neck: supple, without increased JVP, lymphadenopathy or bruits. No thyromegaly,Chest: coarse rhonchi bilaterally,CV: tachycardia, regular, no murmurs, gallops, rubs,Abd: hypoactive bowel sounds, soft, slightly distended, mild tenderness throughout. No rebound, no masses or hepatosplenomegaly.,Ext: no cyanosis, clubbing, or edema. 2+ pulses bilateral distal extremities, no petechiae or splinter hemorrhages.,Neuro: lethargic, but arousable, oriented to person, but not to place, or time. He was not able to answer questions appropriately. Moved all extremities equally but was uncooperative with exam. 2+ DTRs bilaterally, no Babinski reflex.,Skin: no rash, ecchymosis, or petechiae,STUDIES:,EKG: sinus tachycardia, normal axis, isolated Q in III, no TWI or ST elevations or depressions,CXR: Heart normal in size, pulmonary vasculature unremarkable, subsegmental atelectasis in the lower lobes. Acromioclavicular osteoarthritis bilaterally. Lucent lesion in the subchondral bone of the R humeral head, likely a degenerative subchondral cyst.,AXR: Minimal dilation of the small bowel loops in the mid abdomen measuring up to 3cm, no mass lesion or free air visible.,MRI brain pre and post gadolinium: No evidence of hemorrhage, abnormal enhancement, mass lesions, mass effect or edema. The ventricles, sulci, and cisterns are age appropriate in size and configuration. There is no evidence for restricted diffusion. There is mucosal thickening lining the walls of the left maxillary sinus, also containing an air fluid level with two different levels within it, most likely from proteinaceous differences. There is mucosal thickening along the posterior wall of the right maxillary sinus. Mucosal thickening is identified along the walls of the sphenoid sinus, ethmoid sinuses and frontal sinus. Sinusitis with chronic and acute features.,Echo: EF 50%, mild LV concentric hypertrophy, otherwise normal chamber sizes and function,TEE: Normal valves, no thrombi, PFO with R to L shunt, trivial MR, trivial TR,RLE Ultrasound with Dopplers – total deep venous obstruction in distal external iliac, common femoral, profunda femoral, and femoral vein, partial DVT in popliteal and posterior tibial veins, and total DVT greater saphenous vein. No venous obstruction on the L LE. R calf 34cm, R thigh 42 cm, L calf 31cm, L thigh 39cm.,CT Abdomen (initial ER visit): Trace bilateral pleural fluid, findings in liver compatible with diffuse fatty infiltration, 3.5cm non calcified R adrenal mass was noted, along with an edematous L adrenal with no discrete mass. There was retroperitoneal edema around the lower abdominal aorta with perinephric stranding, no stone or obstruction. Moderate fullness of small bowel loops was noted, most consistent with a paralytic ileus.,Hospital Course:, The patient developed right lower extremity swelling and was diagnosed with deep venous thrombosis. Diagnostic studies were performed."
} | [
{
"label": " General Medicine",
"score": 1
}
] | Argilla | null | null | false | null | c72cc6fd-e77f-491b-8730-4db30b891bd3 | null | Default | 2022-12-07T09:38:11.896634 | {
"text_length": 5781
} |
PREOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-c4 and C4-C5.,2. Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-C4 and C4-C5.,2. Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1. Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2. Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3. Anterior cervical fusion, C3-C4 (CPT 22554),4. Anterior cervical fusion, C4-C5 (CPT 22585).,5. Utilization of allograft for purposes of spinal fusion (CPT 20931).,6. Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE INDICATIONS: ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. We discussed the diagnosis and the treatment options. Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5. We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. Furthermore I explained that the fusion may not become solid or that the hardware could break. We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation. I explained the rationale for this as well as the options of using his own bone. Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. He was then positioned supine on the operating table, and all bony prominences were padded. Pulse oximetry was maintained on both feet throughout the case. The arms were carefully padded and tucked at his sides. A roll was placed between the shoulder blades. The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. Ten pounds of traction was applied. A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle. This was then split in line with its fibers. Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. A needle was placed into a disc and an x-ray was done to determine its location. The longus colli muscles were then elevated bilaterally with the electrocautery unit. Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5. This included complete removal of the anterior annulus, nucleus, and posterior annulus. The posterior longitudinal ligament was removed as were the posterior osteophytes. Foraminotomies were then accomplished bilaterally. Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace. Bleeding cancellous bone was exposed. The disc spaces were measured and appropriate size allografts were placed sterilely onto the field. After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. Two screws were then placed into each of the vertebral bodies at C3, C4, and C5. There was excellent purchase. A final x-ray was done confirming good position of the hardware and grafts. The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks. The carotid pulse was strong. A drain was placed deep to the level of the platysma muscle and left at the level of the hardware. The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure. Steri-Strips were placed followed by application of a sterile dressing. The drain was hooked to bulb suction. A Philadelphia collar was applied.,The cranial tongs were carefully removed. The soft tissue overlying the puncture site was massaged to free it up from the underlying bone. There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well. | {
"text": "PREOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-c4 and C4-C5.,2. Cervical spondylotic myelopathy.,POSTOPERATIVE DIAGNOSES,1. Cervical spinal stenosis, C3-C4 and C4-C5.,2. Cervical spondylotic myelopathy.,OPERATIVE PROCEDURES,1. Radical anterior discectomy, C3-C4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63075).,2. Radical anterior discectomy C4-C5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (CPT 63076).,3. Anterior cervical fusion, C3-C4 (CPT 22554),4. Anterior cervical fusion, C4-C5 (CPT 22585).,5. Utilization of allograft for purposes of spinal fusion (CPT 20931).,6. Application of anterior cervical locking plate C3-C5 (CPT 22845).,ANESTHESIA:, General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: ,250 cc.,OPERATIVE INDICATIONS: ,The patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. His MRI confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. We discussed the diagnosis and the treatment options. Due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, I recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. I explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at C3-C4 and C4-C5. We reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. Furthermore I explained that the fusion may not become solid or that the hardware could break. We discussed various techniques available for obtaining fusion and I recommended allograft and plate fixation. I explained the rationale for this as well as the options of using his own bone. Furthermore, I explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,OPERATIVE TECHNIQUE: , After obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. He was then positioned supine on the operating table, and all bony prominences were padded. Pulse oximetry was maintained on both feet throughout the case. The arms were carefully padded and tucked at his sides. A roll was placed between the shoulder blades. The areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. Ten pounds of traction was applied. A needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. The entire neck was then sterilely prepped and draped in the usual fashion.,A transverse skin incision was made and carried down to the platysma muscle. This was then split in line with its fibers. Blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. A needle was placed into a disc and an x-ray was done to determine its location. The longus colli muscles were then elevated bilaterally with the electrocautery unit. Self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,Radical anterior discectomies were performed at C3-C4 and C4-C5. This included complete removal of the anterior annulus, nucleus, and posterior annulus. The posterior longitudinal ligament was removed as were the posterior osteophytes. Foraminotomies were then accomplished bilaterally. Once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. The central canal was wide open at each level as were the foramen.,A high-speed bur was used to remove the cartilaginous endplates above and below each interspace. Bleeding cancellous bone was exposed. The disc spaces were measured and appropriate size allografts were placed sterilely onto the field. After further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. There was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. All weight was then removed from the crania tongs.,The appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. Two screws were then placed into each of the vertebral bodies at C3, C4, and C5. There was excellent purchase. A final x-ray was done confirming good position of the hardware and grafts. The locking screws were then applied, also with excellent purchase.,Following a final copious irrigation, there was good hemostasis and no dural leaks. The carotid pulse was strong. A drain was placed deep to the level of the platysma muscle and left at the level of the hardware. The wounds were then closed in layers using 4-0 Vicryl suture for the platysma muscle, 4-0 Vicryl suture for the subcutaneous tissue, and 4-0 Vicryl suture in a subcuticular skin closure. Steri-Strips were placed followed by application of a sterile dressing. The drain was hooked to bulb suction. A Philadelphia collar was applied.,The cranial tongs were carefully removed. The soft tissue overlying the puncture site was massaged to free it up from the underlying bone. There was good hemostasis.,The patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c738d02d-3193-4f09-9398-e9f109879863 | null | Default | 2022-12-07T09:36:31.288661 | {
"text_length": 6187
} |
PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC. | {
"text": "PREOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1. Mass, left second toe.,2. Tumor.,3. Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1. Excision of mass, left second toe.,2. Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:, An IV was instituted by the Department of Anesthesia in the preoperative holding area. The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap. Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff. After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion. The foot was elevated from the operating table and exsanguinated with an Esmarch bandage. Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses. The foot was lowered to the operating table. The stockinet was reflected and the foot was cleansed with wet and dry sponge. A distal Syme's incision was planned over the distal aspect of the left hallux. The incision was performed with a #10 blade and deepened with #15 down to the level of bone. The dorsal skin flap was removed and dissected in toto off of the distal phalanx. There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx. The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer. Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen. At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx. The area was inspected for any remaining suspicious tissues. Any suspicious tissue was removed. The area was then flushed with copious amounts of sterile saline. The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe. There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe. A linear incision was made just medial to the tissue mass. The mass was then dissected from the overlying skin and off of the underlying capsule. This tissue mass was hard, round, and pearly-gray in appearance. It does not invade into any other surrounding tissues. The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon. Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap. The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot. The patient tolerated the above procedure and anesthesia well without complications. The patient was transported to PACU with vital signs stable and vascular status intact. The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed. The patient will be contacted immediately pending the results of pathology. Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC."
} | [
{
"label": " Surgery",
"score": 1
}
] | Argilla | null | null | false | null | c756a329-e4f4-4ba6-baff-f232a5cac495 | null | Default | 2022-12-07T09:33:08.716555 | {
"text_length": 4005
} |
PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct. | {
"text": "PREOPERATIVE DIAGNOSIS:, Right AC separation.,POSTOPERATIVE DIAGNOSIS:, Right AC separation.,PROCEDURES:, Removal of the hardware and revision of right AC separation.,ANESTHESIA:, General.,BLOOD LOSS:, 100 cc.,COMPLICATIONS:, None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table. After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion. The incision was reopened and the hardware was removed without difficulty. The AC joint was inspected and reduced. An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle. And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability. This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy. The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied. He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c75dbf1a-3b49-49d1-a8ae-2198f3faba3d | null | Default | 2022-12-07T09:36:33.041326 | {
"text_length": 1437
} |
PREOPERATIVE DIAGNOSIS:, Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Massive rotator cuff tear, right shoulder.,2. Near complete biceps tendon tear, right shoulder.,3. Chondromalacia of glenohumeral joint, right shoulder.,4. Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED: ,1. Arthroscopy of the arthroscopic glenoid labrum.,2. Rotator cuff debridement shaving glenoid and humeral head.,3. Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed. He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention. This was gradually done over a period of time. No specific accident or injury could be seen or pointed. He was refractory to conservative outpatient therapy. After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion. He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated. His rotator interval was resolved as well as his subscapularis with tearing. The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe. Glenoid labrum had degenerative tear in the inferior surface. Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position. He was prepped and draped in the usual sterile manner. The portals were created outside the end posteriorly and then anteriorly. A full and complete diagnostic arthroscopy was carried out with the above-noted findings. The shaver was placed anteriorly. Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed. Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out. Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity. No osteophytes were present. Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring. There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this. We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly. We took this back to the level of coracoid base. We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn. Because of this, further debridement was carried out. Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge. Care was taken to not to debride deeper than that. This was done prior to the above.,All instrumentation was removed. A Pain-Buster catheter was placed into a separate anterolateral portal cut to length. Interrupted #4-0 nylon was utilized for portal closures. Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling. He was transferred to his cart and to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology. | {
"text": "PREOPERATIVE DIAGNOSIS:, Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1. Massive rotator cuff tear, right shoulder.,2. Near complete biceps tendon tear, right shoulder.,3. Chondromalacia of glenohumeral joint, right shoulder.,4. Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED: ,1. Arthroscopy of the arthroscopic glenoid labrum.,2. Rotator cuff debridement shaving glenoid and humeral head.,3. Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital. This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed. He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention. This was gradually done over a period of time. No specific accident or injury could be seen or pointed. He was refractory to conservative outpatient therapy. After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion. He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated. His rotator interval was resolved as well as his subscapularis with tearing. The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe. Glenoid labrum had degenerative tear in the inferior surface. Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table. After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position. He was prepped and draped in the usual sterile manner. The portals were created outside the end posteriorly and then anteriorly. A full and complete diagnostic arthroscopy was carried out with the above-noted findings. The shaver was placed anteriorly. Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed. Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out. Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity. No osteophytes were present. Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring. There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this. We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly. We took this back to the level of coracoid base. We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn. Because of this, further debridement was carried out. Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge. Care was taken to not to debride deeper than that. This was done prior to the above.,All instrumentation was removed. A Pain-Buster catheter was placed into a separate anterolateral portal cut to length. Interrupted #4-0 nylon was utilized for portal closures. Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling. He was transferred to his cart and to the PACU in apparent satisfactory condition. Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology."
} | [
{
"label": " Orthopedic",
"score": 1
}
] | Argilla | null | null | false | null | c7640de0-42ad-4646-bdfe-246a2a7ba6fe | null | Default | 2022-12-07T09:36:28.488498 | {
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} |
Subsets and Splits