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He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. | [
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"medical_specialty": " Bariatrics"
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He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. , | [
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Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox. | [
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He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. | [
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He wants to go to surgery. | [
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I will see him in few weeks before the planned date of surgery. | [
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REASON FOR VISIT:, Preop evaluation regarding gastric bypass surgery. | [
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,The patient has gone through the evaluation process and has been cleared from psychological, nutritional, and cardiac standpoint, also had great success on the preop Medifast diet. | [
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,PHYSICAL EXAMINATION: , The patient is alert and oriented x3. | [
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Temperature of 97.9, pulse of 76, blood pressure of 114/74, weight of 247.4 pounds. | [
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Abdomen: Soft, nontender, and nondistended. | [
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,ASSESSMENT AND PLAN:, The patient is currently in stable condition with morbid obesity, scheduled for gastric bypass surgery in less than two weeks. | [
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Risks and benefits of the procedure were reiterated with the patient and significant other and mother, which included but not limited to death, pulmonary embolism, anastomotic leak, reoperation, prolonged hospitalization, stricture, small bowel obstruction, bleeding, and infection. | [
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We will continue on the Medifast diet until the time of surgery and cleared for surgery. | [
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HISTORY: , The patient is scheduled for laparoscopic gastric bypass. | [
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In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. , | [
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She was on laparoscopic gastric bypass for weight loss. , | [
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,PHYSICAL EXAMINATION:, On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80. | [
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Abdomen is soft, nontender. | [
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There is stigmata for morbid obesity. | [
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She has cesarean section scars in the lower abdomen with no herniation. , | [
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DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. | [
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I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., | [
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with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. , | [
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Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed. | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:15:38.847594 | null |
The patient would alert us for earlier intervention. | [
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Symptomatic gallstone formation secondary to rapid weight loss were also discussed. | [
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Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., | [
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She wants to go to surgery. , | [
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In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities. | [
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She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery. | [
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I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time. | [
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PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath. | [
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,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy. | [
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,SOCIAL HISTORY: , She is single. | [
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She drinks alcohol once a week. | [
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,FAMILY HISTORY: , Pertinent for obesity and hypertension. | [
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,ALLERGIES: , She has no known drug allergies. | [
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,PHYSICAL EXAM: ,This is a pleasant female in no acute distress. | [
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Alert and oriented x 3. | [
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HEENT: Normocephalic, atraumatic. | [
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Extraocular muscles intact, nonicteric sclerae. | [
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Cardiovascular is normal sinus rhythm. | [
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Abdomen is obese, soft, nontender and nondistended. | [
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Extremities show no edema, clubbing or cyanosis. | [
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,ASSESSMENT/PLAN: ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band. | [
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ABC will be asking for a letter of medical necessity from Dr. XYZ. | [
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She will also see my nutritionist and social worker and have an upper endoscopy. | [
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Once this is completed, we will submit her to her insurance company for approval. | [
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SUMMARY OF CLINICAL HISTORY:, The patient was a 35-year-old African-American male with no significant past medical history who called EMS with shortness of breath and chest pain. | [
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Upon EMS arrival, patient was tachypneic at 40 breaths per minute with oxygen saturation of 90%. | [
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At the scene, EMS administered breathing treatments and checked lung sounds that did not reveal any evidence of fluid in the lung fields. | [
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Two minutes after arrival at UTMB at 1500, the patient became unresponsive, apneic, and had oxygen saturations from 80-90%. | [
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The patient's heart rate decreased to asystole, was intubated with good breath sounds and air movement. | [
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{
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},
{
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"start": 73
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.864797 | null |
Patient then had wide complex bradycardia and ACLS protocol for pulseless electrical activity was followed for 45 minutes. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.865286 | null |
Bedside echocardiogram showed no pericardial effusion. | [
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] | [
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{
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"label": "KEYPHRASE",
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.866096 | null |
The patient was administered D5W, Narcan, and multiple rounds of epinephrine and atropine, calcium chloride, and sodium bicarbonate. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.866589 | null |
The patient had three episodes of ventricular tachycardia/fibrillation with cardioversion/defibrillation resulting in asystole. | [
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{
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"start": 77
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.867083 | null |
The patient was pronounced dead at 1605 with fixed, dilated pupils, no heart sounds, no pulse and no spontaneous respirations. | [
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{
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"label": "KEYPHRASE",
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.867605 | null |
,DESCRIPTION OF GROSS LESIONS,EXTERNAL EXAMINATION:, The body is that of a 35-year-old well-developed, well-nourished male. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.868157 | null |
There is no peripheral edema of the extremities. | [
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{
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"label": "KEYPHRASE",
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"start": 37
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.868614 | null |
There is an area of congestion/erythema on the upper chest and anterior neck. | [
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{
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.869079 | null |
There are multiple small areas of hemorrhage bilaterally in the conjunctiva. | [
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},
{
"end": 76,
"label": "KEYPHRASE",
"score": 0,
"start": 65
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.869590 | null |
A nasogastric tube and endotracheal tube are in place. | [
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{
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"score": 0,
"start": 24
},
{
"end": 54,
"label": "KEYPHRASE",
"score": 0,
"start": 49
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.870049 | null |
There is an intravenous line in the right hand and left femoral region. | [
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{
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"start": 43
},
{
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"label": "KEYPHRASE",
"score": 0,
"start": 57
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.870502 | null |
The patient has multiple lead pads on the thorax. | [
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{
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"score": 0,
"start": 26
},
{
"end": 35,
"label": "KEYPHRASE",
"score": 0,
"start": 31
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.870941 | null |
The patient has no other major surgical scars. | [
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"scars",
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] | [
{
"end": 40,
"label": "KEYPHRASE",
"score": 0,
"start": 32
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.871369 | null |
,INTERNAL EXAMINATION (BODY CAVITIES):, The right and left pleural cavity contains 10 ml of clear fluid with no adhesions. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.871855 | null |
The pericardial sac is yellow, glistening without adhesions or fibrosis and contains 30 ml of a straw colored fluid. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.872415 | null |
There is minimal fluid in the peritoneal cavity. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 31
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.872866 | null |
,HEART:, The heart is large with a normal shape and a weight of 400 grams. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.873336 | null |
The pericardium is intact. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.873765 | null |
Upon opening the heart was grossly normal without evidence of infarction. | [
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{
"end": 73,
"label": "KEYPHRASE",
"score": 0,
"start": 63
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.874978 | null |
There were slightly raised white plaques in the left ventricle wall lining. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 64
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.875441 | null |
The left ventricle measures 2.2 cm, the right ventricle measures 0.2 cm, the tricuspid ring measures 11 cm, the pulmonic right measures 8 cm, the mitral ring measures 10.2 cm, and the aortic ring measures 7 cm. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.876046 | null |
The foramen ovale is closed. | [
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] | [
{
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"label": "KEYPHRASE",
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"start": 5
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.876521 | null |
The circulation is left dominant. | [
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] | [
{
"end": 16,
"label": "KEYPHRASE",
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"start": 5
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.876930 | null |
Examination of the great vessels of the heart reveals minimal atherosclerosis with the area of greatest stenosis (20% stenosis) at the bifurcation of the LAD.,AORTA:, There is minimal atherosclerosis with no measurable plaques along the full length of the ascending and descending aorta. | [
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{
"end": 288,
"label": "KEYPHRASE",
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"start": 272
}
] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.877554 | null |
,LUNGS: , The right lung weighed 630 grams, the left weighed 710 grams. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.878087 | null |
The lung parenchyma is pink without evidence of congestion of hemorrhage. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.878535 | null |
The bronchi are grossly normal. | [
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"start": 25
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.878960 | null |
In the right lung, there are two large organizing thrombo-emboli. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.879408 | null |
The first is located at the first branch of the pulmonary artery with an older, organizing area adherent to the vessel wall measuring 1.0 x 1.0 x 2.5 cm. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.879942 | null |
Surrounding this organizing area is a newer area of apparent thrombosis completely occluding the bifurcation. | [
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"medical_specialty": " Autopsy"
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There are multiple other emboli located in smaller pulmonary vessels that show evidence of distending the vessels they are located inside. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.881402 | null |
,GASTROINTESTINAL SYSTEM:, The esophagus and stomach are normal in appearance without evidence of ulcers or varices. | [
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The stomach contains approximately 800 ml, without evidence of any pills or other non-foodstuff material. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.882394 | null |
The pancreas shows a normal lobular cut surface with evidence of autolysis. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.882849 | null |
The duodenum, ileum, jejunum and colon are all grossly normal without evidence of abnormal vasculature or diverticula. | [
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} | Default | 2022-12-07T10:15:38.883333 | null |
An appendix is present and is unremarkable. | [
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} | Default | 2022-12-07T10:15:38.883773 | null |
The liver weighs 2850 grams and the cut surface reveals a normal liver with no fibrosis present grossly. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.884247 | null |
The gallbladder is in place with a probe patent bile duct through to the ampulla of Vater. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.884746 | null |
,RETICULOENDOTHELIAL SYSTEM:, The spleen is large weighing 340 grams, the cut surface reveals a normal appearing white and red pulp. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.885280 | null |
No abnormally large lymph nodes were noted. | [
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,GENITOURINARY SYSTEM:, The right kidney weighs 200 grams, the left weighs 210 grams. | [
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} | Default | 2022-12-07T10:15:38.886180 | null |
The left kidney contains a 1.0 x 1.0 x 1.0 simple cyst containing a clear fluid. | [
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} | Default | 2022-12-07T10:15:38.886649 | null |
The cut surface reveals a normal appearing cortex and medulla with intact calyces. | [
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} | Default | 2022-12-07T10:15:38.887121 | null |
The prostate and seminal vessels were cut revealing normal appearing prostate and seminal vesicle tissue without evidence of inflammation or embolus. | [
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"medical_specialty": " Autopsy"
} | Default | 2022-12-07T10:15:38.887631 | null |
,ENDOCRINE SYSTEM:, The adrenal glands are in the normal position and weigh 8.0 grams on the right and 11.6 grams on the left. | [
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The cut surface of the adrenal glands reveals a normal appearing cortex and medulla. | [
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