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,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.071513 | null |
She was alert and oriented in no apparent distress. | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.071718 | null |
,PROCEDURE: ,I was able to access her port. | [
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} | Default | 2022-12-07T10:14:27.071886 | null |
I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure. | [
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} | Default | 2022-12-07T10:14:27.072229 | null |
,ASSESSMENT:, The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure. | [
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} | Default | 2022-12-07T10:14:27.072493 | null |
PROCEDURE: , Elective male sterilization via bilateral vasectomy. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.075645 | null |
,PREOPERATIVE DIAGNOSIS: ,Fertile male with completed family. | [
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} | Default | 2022-12-07T10:14:27.075850 | null |
,POSTOPERATIVE DIAGNOSIS:, Fertile male with completed family. | [
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} | Default | 2022-12-07T10:14:27.076041 | null |
,MEDICATIONS: ,Anesthesia is local with conscious sedation. | [
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,INDICATIONS: ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. | [
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He has been given prophylactic antibiotics. | [
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,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. | [
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The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. | [
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} | Default | 2022-12-07T10:14:27.077764 | null |
The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath. | [
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The vas was brought out of the incision carefully. | [
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The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. | [
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The vas was grasped and brought up to the level of the skin. | [
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The vas was brought out of the incision carefully. | [
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} | Default | 2022-12-07T10:14:27.080684 | null |
,Bacitracin ointment was applied as well as dry sterile dressing. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:14:27.080922 | null |
The patient was awakened and was returned to Recovery in satisfactory condition. | [
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} | Default | 2022-12-07T10:14:27.081154 | null |
HISTORY OF PRESENT ILLNESS:, The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room. | [
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She was intubated and fishbone. | [
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"medical_specialty": " General Medicine"
} | Default | 2022-12-07T10:14:27.084207 | null |
,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract. | [
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] | Argilla | null | null | null | {
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,ALLERGIES: ,No known drug allergies. | [
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] | Argilla | null | null | null | {
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,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco. | [
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] | Argilla | null | null | null | {
"medical_specialty": " General Medicine"
} | Default | 2022-12-07T10:14:27.085087 | null |
,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed. | [
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The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated. | [
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If not she would require tracheostomy. | [
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The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated. | [
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"medical_specialty": " General Medicine"
} | Default | 2022-12-07T10:14:27.086501 | null |
She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. | [
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So, the patient is being prepared for discharge at this point. | [
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} | Default | 2022-12-07T10:14:27.086979 | null |
,TECHNIQUE:, 3.5 hours following the intravenous administration of 26.5 mCi of Technetium 99m MDP, the skeleton was imaged in the anterior and posterior projections. | [
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"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.089053 | null |
,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. | [
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The uptake in the remainder of the skeleton is within normal limits. | [
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The kidneys image normally. | [
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There is increased activity in the urinary bladder suggesting possible urinary retention. | [
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Focus of abnormal increased tracer activity overlying the right parietal region of the skull. | [
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CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated. | [
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There is probably some degree of urinary retention., | [
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Morbid obesity, status post laparoscopic Roux-en-Y gastric bypass. , | [
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"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.094241 | null |
Obstructive sleep apnea, on CPAP.,OPERATION AND PROCEDURE: , Laparoscopic Roux-en-Y gastric bypass. | [
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} | Default | 2022-12-07T10:14:27.094774 | null |
,BRIEF HOSPITAL COURSE SUMMARY: ,This is a 30-year-old male, who presented recently to the Bariatric Center for evaluation and treatment of longstanding morbid obesity and associated comorbidities. | [
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} | Default | 2022-12-07T10:14:27.095084 | null |
Underwent standard bariatric evaluation, consults, diagnostics, and preop Medifast induced weight loss in anticipation of elective bariatric surgery. , | [
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} | Default | 2022-12-07T10:14:27.095361 | null |
Taken to the OR via same day surgery process for elective gastric bypass, tolerated well, recovered in the PACU, and sent to the floor for routine postoperative care. | [
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} | Default | 2022-12-07T10:14:27.095696 | null |
There, DVT prophylaxis was continued with subcu heparin, early and frequent mobilization, and SCDs. | [
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PCA was utilized for pain control, efficaciously, he utilized the CPAP, was monitored, and had no new cardiopulmonary complaints. | [
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} | Default | 2022-12-07T10:14:27.096180 | null |
Postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well. | [
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He was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.096670 | null |
By the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today. | [
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} | Default | 2022-12-07T10:14:27.096952 | null |
,DISCHARGE INSTRUCTIONS: , Include re-appointment in the office in the next week, call in the interim if any significant concerning complaints. | [
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} | Default | 2022-12-07T10:14:27.097343 | null |
He will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.097870 | null |
Can shower starting tomorrow, drain site care and wound care reviewed. | [
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"score": 0,
"start": 31
},
{
"end": 46,
"label": "KEYPHRASE",
"score": 0,
"start": 42
},
{
"end": 61,
"label": "KEYPHRASE",
"score": 0,
"start": 51
}
] | Argilla | null | null | null | {
"medical_specialty": " Bariatrics"
} | Default | 2022-12-07T10:14:27.098086 | null |
DESCRIPTION:, The patient was placed in the supine position and was prepped and draped in the usual manner. | [
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.099559 | null |
The left vas was grasped in between the fingers. | [
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{
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"score": 0,
"start": 41
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.099861 | null |
The skin and vas were anesthetized with local anesthesia. | [
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},
{
"end": 57,
"label": "KEYPHRASE",
"score": 0,
"start": 47
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.100100 | null |
The vas was grasped with an Allis clamp. | [
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] | [
{
"end": 20,
"label": "KEYPHRASE",
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"start": 5
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.100291 | null |
Skin was incised and the vas deferens was regrasped with another Allis clamp. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.100462 | null |
The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.100708 | null |
The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. | [
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"score": 0,
"start": 112
},
{
"end": 151,
"label": "KEYPHRASE",
"score": 0,
"start": 143
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.100985 | null |
The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion. | [
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"score": 0,
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{
"end": 102,
"label": "KEYPHRASE",
"score": 0,
"start": 95
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.101214 | null |
Dry sterile dressings were applied and the patient put on a scrotal supporter. | [
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{
"end": 78,
"label": "KEYPHRASE",
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"start": 61
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.101525 | null |
PREOPERATIVE DIAGNOSIS: , Voluntary sterility. | [
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] | [
{
"end": 45,
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.104258 | null |
,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility. | [
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] | [
{
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"start": 38
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.104455 | null |
,OPERATIVE PROCEDURE:, Bilateral vasectomy. | [
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] | [
{
"end": 43,
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.104621 | null |
,INDICATIONS FOR PROCEDURE: ,A gentleman who is here today requesting voluntary sterility. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.104940 | null |
Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy. | [
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{
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"start": 85
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.105160 | null |
,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.105506 | null |
Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.105750 | null |
A small incision was made in the right hemiscrotum. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.105933 | null |
The vas deferens was grasped with a vas clamp. | [
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{
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"label": "KEYPHRASE",
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"start": 37
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106108 | null |
Next, the vas deferens was skeletonized. | [
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{
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"label": "KEYPHRASE",
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"start": 28
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106290 | null |
It was clipped proximally and distally twice. | [
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{
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"start": 16
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106463 | null |
The cut edges were fulgurated. | [
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{
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},
{
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"label": "KEYPHRASE",
"score": 0,
"start": 20
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106621 | null |
Meticulous hemostasis was maintained. | [
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{
"end": 22,
"label": "KEYPHRASE",
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106776 | null |
Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.106979 | null |
Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum. | [
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.107257 | null |
The vas deferens was isolated. | [
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{
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.107442 | null |
It was skeletonized. | [
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] | [
{
"end": 20,
"label": "KEYPHRASE",
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"start": 8
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.107582 | null |
It was clipped proximally and distally twice. | [
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] | [
{
"end": 39,
"label": "KEYPHRASE",
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"start": 16
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.107738 | null |
The cut edges were fulgurated. | [
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{
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},
{
"end": 30,
"label": "KEYPHRASE",
"score": 0,
"start": 20
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.107886 | null |
Meticulous hemostasis was maintained. | [
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] | [
{
"end": 22,
"label": "KEYPHRASE",
"score": 0,
"start": 12
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.108056 | null |
Then, 4-0 chromic was used to close the scrotal skin. | [
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"start": 41
},
{
"end": 53,
"label": "KEYPHRASE",
"score": 0,
"start": 49
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.108257 | null |
A jockstrap and sterile dressing were applied at the end of the case. | [
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{
"end": 33,
"label": "KEYPHRASE",
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.108472 | null |
Sponge, needle, and instruments counts were correct. | [
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] | [
{
"end": 15,
"label": "KEYPHRASE",
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"start": 9
}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.108658 | null |
DIAGNOSIS:, Desires vasectomy. | [
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] | [
{
"end": 30,
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.109967 | null |
,HISTORY: , Patient, 37, desires a vasectomy. | [
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}
] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.110260 | null |
,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.110616 | null |
No bleeding was identified. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.110846 | null |
,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound. | [
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"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.111078 | null |
Again no bleeding was noted. | [
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"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.111226 | null |
,The wound was closed with 4-0 Vicryl times two. | [
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"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.111369 | null |
A sterile dressing was applied. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.111576 | null |
He was awakened and transferred to the recovery room in stable condition. | [
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} | Default | 2022-12-07T10:14:27.111727 | null |
PROCEDURES:, Cystourethroscopy and transurethral resection of prostate. | [
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} | Default | 2022-12-07T10:14:27.113961 | null |
,ADMITTING DIAGNOSIS:, Difficulty voiding. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.114202 | null |
,HISTORY:, This 67-year old Hispanic male patient was admitted because of enlarged prostate and symptoms of bladder neck obstruction. | [
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"medical_specialty": " Urology"
} | Default | 2022-12-07T10:14:27.114416 | null |