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CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104. HR 92. RR 12. Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.neurology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody,

HISTORY:, The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis. He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation. These procedures were performed at Medical College Hospital. Family states that they moved to the United States. Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery. He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg. The QP:QS ratio of 0.6:1. A large decompressing venous collateral was also appreciated. The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta. A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful. Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein. Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire. This catheter then also advanced into the bridging innominate vein. The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava. A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery. There was no vascular continuity to the stump of the right Glenn. The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava. The Bernstein catheter was then reintroduced using a Terumo guidewire. Probing of the superior vena cava facilitated access into the right lower pulmonary artery. The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis. The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length. The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist. This facilitated advancement of a flexor sheath into the proximal portion of the stenosis. A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe. A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist. Angiogram demonstrated a good stent apposition to the caval wall. Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist. Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery. The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery. Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery. Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery. Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist. Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery. The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist. Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter. Repeat angiograms were then performed. Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein. A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter. An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein. Once stable device was confirmed, the device was released from the delivery catheter. The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein. A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION:, Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%. The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen. Remaining saturations reflected complete admixture. There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow. Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg. Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta. Phasic ascending, descending pressures were similar and normal. Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg. The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1. The pulmonary vascular resistance was elevated at 4.4 Woods units. Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg. Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation. There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg. There was an increase in arterial pressure. The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared. Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava. There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient. There was absence of contrast filling of the right middle and right upper pulmonary artery. Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow. Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES: ,1. Asplenia syndrome.,2. Dextrocardia bilateral superior vena cava.,3. Atrioventricular septal defect.,4. Total anomalous pulmonary venous return to the right-sided atrium.,5. Double outlet right ventricle with malposed great vessels.,6. Severe pulmonary stenosis.,7. Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Right modified Blalock-Taussig shunt.,2. Bilateral bidirectional Glenn shunt.,3. Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES: ,1. Obstructed right caval pulmonary anastomosis.,2. Obstructed right proximal pulmonary artery.,3. Venovenous collateral vessel.,CURRENT INTERVENTION: ,1. Balloon dilation of the right superior vena cava and stent implantation.,2. Balloon dilation of the proximal right pulmonary artery, stent implantation.,3. Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference. A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion. The patient will be maintained on anticoagulant medications of aspirin and Plavix. Further cardiology care will be directed by Dr. X.nan

CC:, Left hemiplegia.,HX: , A 58 y/o RHF awoke at 1:00AM on 10/23/92 with left hemiplegia and dysarthria which cleared within 15 minutes. She was seen at a local ER and neurological exam and CT Brain were reportedly unremarkable. She was admitted locally. She then had two more similar spells at 3AM and 11AM with resolution of the symptoms within an hour. She was placed on IV Heparin following the 3rd episode and was transferred to UIHC. She had not been taking ASA.,PMH:, 1)HTN. 2) Psoriasis.,SHX:, denied ETOH/Tobacco/illicit drug use.,FHX:, Unknown.,MEDS:, Heparin only.,EXAM:, BP160/90 HR145 (supine). BP105/35 HR128 (light headed, standing) RR12 T37.7C,MS: Dysarthria only. Lucid thought process.,CN: left lower facial weakness only.,Motor: mild left hemiparesis with normal muscle bulk. Mildly increased left sided muscle tone.,Sensory: unremarkable.,Coordination: impaired secondary to weakness on left. Otherwise unremarkable.,Station: left pronator drift. Romberg testing not done.,Gait: not tested.,Reflexes: symmetric; 2+ throughout.,Gen Exam: CV: Tachycardic without murmur.,COURSE:, The patients signs and symptoms worsening during and after standing to check orthostatic blood pressures. She was immediately placed in a reverse Trendelenburg position and given IV fluids. Repeat neurologic exam at 5PM on the day of presentation revealed a return to the initial presentation of signs and symptoms. PT/PTT/GS/CBC/ABG were unremarkable. EKG revealed sinus tachycardia with rate dependent junctional changes. CXR unremarkable. MRI Brain was obtained and showed an evolving right thalamic/lentiform nucleus infarction best illustrated by increased signal on the Proton density weighted images. Over the ensuing days of admission she had significant fluctuations of her BP (200mmHG to 140mmHG systolic). Her symptoms worsened with falls in BP. Her BP was initially controlled with esmolol or labetalol. Renal Ultrasound, abdominal/pelvic CT, renal function scan, serum and urine osmolality, urine catecholamines/metanephrine studies were unremarkable. Carotid doppler study revealed 0-15%BICA stenosis and antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram was unremarkable. Cerebral angiogram was performed to r/o vasculitis. This revealed narrowing of the M1 segment of the right MCA. This was thought secondary to atherosclerosis and not vasculitis. She was discharged on ASA, Procardia XL, and Labetalol.neurology, mri brain, ct brain, heparin, dysarthria, hemiplegia, infarct, neurological exam, thalamic, thalamic infarct, mri, brain,

PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee. This operative note will discuss the right total knee arthroplasty.,ANESTHESIA: ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:, This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table. She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity. The right lower extremity was then sterilely prepped and draped in the usual fashion. An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg. Longitudinal incision was made over the anterior aspect of the right knee. Subcutaneous tissue was carefully dissected. A medial parapatellar retinacular incision was made. The patella was then everted and the above noted gross findings were appreciated. A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place. The appropriate cuts were made at the distal femur as well as with use of the chamfer guide. The trial femoral component was then positioned in place and noted to have good fit. Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut. The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments. The remnants of the anterior cruciate ligament and menisci were resected. The tibial trial was positioned in place. Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut. The tibial holes were then drilled. The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella. The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness. Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate. The knee was placed through range of motion with the trial components marked and then the appropriate components obtained. The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed. The femoral component was inserted with methylmethacrylate. Any excessive methylmethacrylate and bony debris were removed from the joint. Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm. The methylmethacrylate was also used at the patella. The prosthesis was positioned in place. The patellar clamp held securely till the methylmethacrylate was firm. After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment. This component was removed and revised to a stemmed component with better alignment and position. The previous component removed, the methylmethacrylate was removed. Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached. The trial tibial stemmed component was positioned in place. Knee was placed through range of motion and the tracking was better. Actual component was then obtained, methyl methacrylate was placed within the tibia. The stemmed tibial component was impacted into place with good fit. The Poly was then positioned in place. Knee held in full extension with compression longitudinally after methylmethacrylate was solidified. The trial Poly was removed. Wound was irrigated and the joint was inspected. There was no debris. Collateral ligaments and posterior cruciate ligaments remained intact. Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component. The tourniquet was deflated. Hemostasis was satisfactory. A drain was placed into the depths of the wound. The medial retinacular incision was closed with one Ethibond suture in interrupted fashion. The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain. The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion. The skin was closed with surgical clips. The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity. At the completion of the procedure, distal pulses were intact. Toes were pink, warm, with good capillary refill. Distal neurovascular status was intact. Postoperative x-ray demonstrated satisfactory alignment of the prosthesis. Prognosis is good in this 79-year-old female with a significant degenerative arthritis.orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,

PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE: ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007. While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture. This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius. The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions. He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago. The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8. The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware. He is taking a job out of state in the next couple of months. Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously. The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout. The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient. A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers. A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator. The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment. The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment. At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws. The ulnar styloid was not affixed in any portion of this repair. The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order. The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order. Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw. Three screws were locking across the die-punch fragment. The remaining two screws were placed into the radial shaft. All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial. The tourniquet time was 1.5 hours. At this point, the tourniquet was let down. The entire construct was irrigated with copious amounts of bacitracin and normal saline. Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound. Several image intensification x-rays were taken at the conclusion of the case to check screw length. Screw lengths were changed out during the case as needed based on the x-ray findings. The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex. A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint. Estimated blood loss was 10 mL. There were no specimens. Tourniquet time was 1.5 hours.orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial

EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord.orthopedic, borderline central canal stenosis, mri cervical spine, borderline central canal, central canal stenosis, degenerative disc, annular bulging, ap diameter, endplate spondylosis, borderline central, canal stenosis, disc desiccation, central canal, cervical, disc, spondylosis, stenosis, cord, canal,

SUBJECTIVE:, The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs: The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004. I praised her weight loss and her regular exercising. I looked at her food journal. I praised her record keeping. I gave her a list of the diabetic exchanges and explained them. I also gave her a food dairy sheet so that she could record exchanges. I encouraged her to continue.,ASSESSMENT:, The patient seems happy with her progress and she seems to be doing well. She needs to continue.,PLAN:, Followup is on a p.r.n. basis. She is always welcome to call or return.consult - history and phy., overeaters anonymous, diabetic exchanges, exercising pretty regularly, food journal, diabetic, exercising, exchanges, regularly

PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the emergency department revealed both-bone forearm fracture. Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction. After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE: ,The patient was induced with propofol for conscious sedation via the emergency department staff. After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture. Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier. The patient was aroused from anesthesia and tolerated the procedure well. Post-reduction plain films revealed some anterior displacement of the distal fragment. At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement. We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,surgery, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture

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.surgery, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

EXAM:, Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality. Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. Ejection fraction is 60% without any obvious wall motion abnormality. Left atrium and right side chambers are of normal size and dimensions. Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification. Valvular leaflet excursion is adequate. Aortic valve reveals annular calcification. Fibrocalcific valve leaflets with decreased excursion. Atrial and ventricular septum are intact. Pericardium is intact without any effusion. No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. Estimated pulmonary pressure of 48. Systolic consistent with mild-to-moderate pulmonary hypertension. Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.radiology, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,

PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.sleep medicine, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index,

PREOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1. Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2. Bilateral breast asymmetry.,3. Right breast macromastia.,4. Right abdominal scar deformity.,5. Left abdominal scar deformity.,6. A 1.3 cm lesion right inferior breast.,7. Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1. Left breast flap revision.,2. Right breast flap revision.,3. Right breast reduction mammoplasty.,4. Right nipple reconstruction.,5. Left abdominal scar deformity.,6. Right abdominal scar deformity.,7. Excision of right breast medial lesion enclosure.,8. Excision of right breast lateral lesion enclosure.,ANESTHESIA:, General.,COMPLICATIONS:, None.,DRAINS:, None.,SPECIMENS:, Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:, This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction. The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated. The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:, The patient was brought to the operating room, placed supine on the operative table. After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant. The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants. Once this was performed, the vertical reduction mammoplasty was outlined. Prior to that, the nipple reconstruction was performed with a keyhole pattern flap. The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie. The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures. Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures. Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions. Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb. Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex. Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology. They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required. Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect. There was a larger excision required measuring approximately 15 x 3 cm. The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures. Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition. All instruments, needle counts, and sponges were correct at the end of the case.nan

PREOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:, Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION: ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. Finally, he has decided to have them get repaired. Plan is for surgical repair.,DESCRIPTION OF OPERATION: ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. IV antibiotics were given. Ancef 1 g given. A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. Electrocautery was used for hemostasis. Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. There was moderate amount of scarring on the testis itself from the tunica vaginalis. It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver. Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly. This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. A similar drain was placed. The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine. IV Toradol was given at the end of the procedure. The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl. Bacitracin dressing, ABD dressing, and jock strap were placed. The patient was in stable condition upon transfer to the recovery room.urology, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,

CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, which she feels to have helped. The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. At that time, the patient also had significant increasing congestion. Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated. A chest x-ray was obtained and was noted to be normal. The patient's saturations were noted to be normal and the patient was discharged home. Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. The patient had a 101 temperature on Wednesday evening, but has had no true fevers. The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS: ,As above.,IMMUNIZATIONS:, None.,PAST MEDICAL HISTORY: ,No hospitalizations. No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery. Birth weight 6 pounds 12 ounces. Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma. Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother. There is one bird. There are smokers in the household. There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE: Nontoxic child, but with increased work of breathing. No respiratory distress.,HEENT: Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.,NECK: Supple. No lymphadenopathy.,CHEST: Exhibits symmetric expansion and retractions.,LUNGS: The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN: Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.,GU: Normal female. No discharge or erythema.,BACK: Normal with a normal curvature.,EXTREMITIES: A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. A urinalysis obtained in the emergency room was noted to be negative. CRP was noted to be 2.0. The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis. At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Currently, at this time, I feel no respiratory treatments are indicated in this patient. I hear no evidence of wheezing or reactive airway disease. We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.nan

PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. The patient was found to have cholelithiasis on last admission. He was being worked up for this including cardiac clearance. However, in the interim, he returned again with another episode of same pain. The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. Because of these, laparoscopic cholecystectomy was advised with cholangiogram. Possibility of open laparotomy and open procedure was also explained to the patient. The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia. The entire abdomen was prepped and draped. A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. The patient has a rather long torso. Fascia was opened vertically and stay sutures were placed in the fascia. Peritoneal cavity was carefully entered. Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2. Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. The patient was placed in reverse Trendelenburg and rotated to the left. An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. Slowly, the dissection was carried out in the right subhepatic area. Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered. A Bookwalter retractor was put in place. The dissection was then carried out on the undersurface of the liver. Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. The duodenum was kocherized. The gallbladder was partly intrahepatic. Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem. The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was. Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short. Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy. This showed a rounded density at the lower end of the bile duct consistent with the stone. At this time, a decision was made to proceed with common duct exploration. The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out. After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. So, it was about a 1-cm size stone, which was removed. Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. No further stones were obtained. The catheter went easily into the duodenum through the ampulla of Vater. At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree. However, a stone was found distally still floating around. This was removed with stone forceps. The bile ducts were irrigated again. No further stones were removed. A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure. A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area. Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area. I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. The bile duct lumen was widely open. T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time. The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. Hemostasis was good. A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site. The T-tube was brought out through the middle 5-mm port site, which was just above the incision. Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia. Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers. Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control. The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin. Sterile dressing was applied, and the patient transferred to recovery room in stable condition.gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder

PREOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,POSTOPERATIVE DIAGNOSES: ,1. Cervical spondylosis C5-C6 greater than C6-C7 (721.0).,2. Neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,PROCEDURES: ,1. Anterior cervical discectomy at C5-C6 and C6-C7 for neural decompression (63075, 63076).,2. Anterior interbody fusion at C5-C6 and C6-C7 (22554, 22585) utilizing Bengal cages x2 (22851).,3. Anterior instrumentation by Uniplate construction C5, C6, and C7 (22845); with intraoperative x-ray x2.,ANESTHESIA: ,General.,OPERATIONS: , The patient was brought to the operating room and placed in the supine position where general anesthesia was administered. Then the anterior aspect of the neck was prepped and draped in the routine sterile fashion. A linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues. Prominent anterior osteophytes once identified and compared to preoperative studies were removed at C5-C6 and then at C6-C7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at C5-6, and even more collapsed at C6-C7. Gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to Pathology in a routine fashion as disc specimen. This was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the C5 and C6 interspaces and at C6-C7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro Kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well. This allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed. At no time during the case was there evidence of CSF leakage and hemostasis was well achieved with pledgets of Gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as Surgifoam. Once hemostasis well achieved, Bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first C5-C6, then secondly at C6-C7. These were checked and found to be well applied and further stability was then added by placement nonetheless of a Uniplate of appropriate size. The appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc. The wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 Vicryl and the skin with subcuticular stitch of #4-0 Vicryl incorporating a Penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,Once the bandage was placed, the patient was taken, extubated from the operating room to the Recovery area, having in stable, but guarded condition. At the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct. There were no intraoperative complications of any type.surgery, cervical spondylosis, anterior cervical discectomy, anterior instrumentation, annulotomy, kerrison rongeurs, surgifoam, vertebral space, uniplate construction, bengal cages, neural decompression, anterior cervical, cervical discectomy, interbody, anterior, cervical, discectomy

Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,IMPRESSION:, Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,

PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS: ,Gross hematuria.,OPERATIONS: ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS: ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed. There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs. The patient had hematuria. Cystoscopy revealed atypical biopsy. The patient came in again with gross hematuria. The first biopsy was done about a month ago. The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. The options of watchful waiting, removal of the clots and biopsies were discussed. Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed. Morbidity and mortality of the procedure were discussed. Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the OR. Anesthesia was applied. The patient was placed in the dorsal lithotomy position. The patient was prepped and draped in the usual sterile fashion. The patient had been off of the Coumadin for about 4 days and INR had been reversed. The patient has significant amount of clot upon entering the bladder. There was a tight bladder neck contracture. The prostate was not enlarged. Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed. It took about half an hour to just remove the clots. After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. This was lateral to the left ureteral opening. The base was coagulated for hemostasis. Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. The back wall and the rest of the bladder appeared normal. Using 8-French cone-tip catheter, left-sided pyelogram was normal. The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. The patient did have CT with contrast, which showed that the kidneys were normal. At this time, a #24 three-way irrigation was started. The patient was brought to Recovery room in stable condition.urology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,

CHIEF COMPLAINT:, Headache.,HPI: , This is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on CT scan. He was discharged home with a follow up to neurosurgery on the 14th. Apparently, an MRI the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. He has had headaches since the 13th and complains now of some worsening of his pain. He denies photophobia, fever, vomiting, and weakness of the arms or legs.,PMH: , As above.,MEDS:, Vicodin.,ALLERGIES:, None.,PHYSICAL EXAM: ,BP 180/110 Pulse 65 RR 18 Temp 97.5.,Mr. P is awake and alert, in no apparent distress.,HEENT: Pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,Neck: Supple, no meningismus.,Lungs: Clear.,Heart: Regular rate and rhythm, no murmur, gallop, or rub. ,Abdomen: Benign.,Neuro: Awake and alert, motor strength normal, no numbness, normal gait, DTRs normal. Cranial nerves normal. ,COURSE IN THE ED: ,Patient had a repeat head CT to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. I recommended an LP but he prefers not to have this done. He received morphine for pain and his headache improved. I've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. He left the ED against my advice. ,IMPRESSION: , Headache, improved. Intracranial aneurysm.,PLAN: , The patient will return tomorrow am for his angiogram.emergency room reports, angiogram, mass, ct scan, intracranial aneurysm, headache, aneurysm, intracranial,

PREOPERATIVE DIAGNOSES:,1. Nasopharyngeal mass.,2. Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1. Nasopharyngeal tube mass.,2. Right upper lid skin lesion.,PROCEDURES PERFORMED:,1. Functional endoscopic sinus surgery.,2. Excision of nasopharyngeal mass via endoscopic technique.,3. Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease. The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan. The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months. It appears to be growing in size and is irregularly bordered. After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position. After this, the patient was turned to 90 degrees by the Department of Anesthesia. The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total. After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total. The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade. After this, the skin lesion was then grasped with a ________ in the superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors. After this, the ________ was then hemostatically controlled with monopolar cauterization. The patient's skin was then reapproximated with a running #6-0 Prolene suture. A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment. Attention then was drawn to the nasopharynx. The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx. The patient had a severely deviated nasal septum more so to the right than the left. There appeared to be a spur on the left inferior aspect and also on the right posterior aspect. The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking. It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total. After this, the lesion was then removed on the right side with the XPS blade. The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely. This area was taken down with the XPS blade. Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter. After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side. The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx. Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius. After this, the patient was then hemostatically controlled with suctioned Bovie cauterization. A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment. The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia. The patient was extubated in the operating room and was transferred to the recovery room in stable condition. The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week. The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.ent - otolaryngology, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,

SOCIAL HISTORY, FAMILY HISTORY, AND PAST MEDICAL HISTORY:, Reviewed. There are no changes, otherwise.,REVIEW OF SYSTEMS:, Fatigue, pain, difficulty with sleep, mood fluctuations, low stamina, mild urgency frequency and hesitancy, preponderance of lack of stamina, preponderance of pain particularly in the left shoulder.,EXAMINATION: , The patient is alert and oriented. Extraocular movements are full. The face is symmetric. The uvula is midline. Speech has normal prosody. Today there is much less guarding of the left shoulder. In the lower extremities, iliopsoas, quadriceps, femoris and tibialis anterior are full. The gait is narrow based and noncircumductive. Rapid alternating movements are slightly off bilaterally. The gait does not have significant slapping characteristics. Sensory examination is largely unremarkable. Heart, lungs, and abdomen are within normal limits.,IMPRESSION: , Mr. ABC is doing about the same. We discussed the issue of adherence to Copaxone. In order to facilitate this, I would like him to take Copaxone every other day, but on a regular rhythm. His wife continues to inject him. He has not been able to start himself on the injections.,Greater than 50% of this 40-minute appointment was devoted to counseling.neurology, neurologic consultation, stamina, preponderance, neurologic, consultation, copaxone,

CHIEF COMPLAINT:, Toothache.,HISTORY OF PRESENT ILLNESS: ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:, PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1. ODONTALGIA.,2. MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION: ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.dentistry, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

CHIEF COMPLAINT (1/1): ,This 24 year-old female presents today complaining of itchy, red rash on feet. Associated signs and symptoms: Associated signs and symptoms include tingling, right. Context: Patient denies any previous history, related trauma or previous treatments for this condition. Duration: Condition has existed for 4 weeks. Location: She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe. Modifying factors: Patient indicates ice improves condition. Quality: Quality of the itch is described by the patient as constant. Severity: Severity of condition is unbearable. Timing (onset/frequency): Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:, None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY: ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:, Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting: 110/64 Resp: 18 HR: 66 Temp: 98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. Cardiovascular: Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed. Skin: Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological: Touch, pin, vibratory and proprioception sensations are normal. Deep tendon reflexes normal.,Musculoskeletal: Muscle strength is 5/5 for all groups tested. Muscle tone is normal. Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:, No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN: ,Obtained fungal culture of skin from right toes. KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:, Lotrimin AF Dosage: 1% cream Sig: apply qid Dispense: 4oz tube Refills: 0 Allow Generic: Yesnan

PREOPERATIVE DIAGNOSIS:, Bilateral upper eyelid dermatochalasis.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE: , Bilateral upper lid blepharoplasty, (CPT 15822).,ANESTHESIA: , Lidocaine with 1:100,000 epinephrine.,DESCRIPTION OF PROCEDURE: , This 65-year-old female demonstrates conditions described above of excess and redundant eyelid skin with puffiness and has requested surgical correction. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated. She has requested this corrective repair be undertaken, and a consent was signed.,The patient was brought into the operating room and placed in the supine position on the operating table. An intravenous line was started, and sedation and sedation anesthesia was administered IV after preoperative p.o. sedation. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously. The excess and redundant skin of the upper lids producing redundancy and impairment of lateral vision was carefully measured, and the incisions were marked for fusiform excision with a marking pen. The surgical calipers were used to measure the supratarsal incisions so that the incision was symmetrical from the ciliary margin bilaterally.,The upper eyelid areas were bilaterally injected with 1% Lidocaine with 1:100,000 Epinephrine for anesthesia and vasoconstriction. The plane of injection was superficial and external to the orbital septum of the upper and lower eyelids bilaterally.,The face was prepped and draped in the usual sterile manner.,After waiting a period of approximately ten minutes for adequate vasoconstriction, the previously outlined excessive skin of the right upper eyelid was excised with blunt dissection. Hemostasis was obtained with a bipolar cautery. A thin strip of orbicularis oculi muscle was excised in order to expose the orbital septum on the right. The defect in the orbital septum was identified, and herniated orbital fat was exposed. The abnormally protruding positions in the medial pocket were carefully excised and the stalk meticulously cauterized with the bipolar cautery unit. A similar procedure was performed exposing herniated portion of the nasal pocket. Great care was taken to obtain perfect hemostasis with this maneuver. A similar procedure of removing skin and taking care of the herniated fat was performed on the left upper eyelid in the same fashion. Careful hemostasis had been obtained on the upper lid areas. The lateral aspects of the upper eyelid incisions were closed with a couple of interrupted 7-0 blue Prolene sutures.,At the end of the operation the patient's vision and extraocular muscle movements were checked and found to be intact. There was no diplopia, no ptosis, no ectropion. Wounds were reexamined for hemostasis, and no hematomas were noted. Cooled saline compresses were placed over the upper and lower eyelid regions bilaterally.,The procedures were completed without complication and tolerated well. The patient left the operating room in satisfactory condition. A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to return home in satisfactory condition.surgery, bilateral upper eyelid dermatochalasis, blepharoplasty, upper lid, bilateral upper lid, eyelid, bilateral upper lid blepharoplasty, upper lid blepharoplasty, eyelid dermatochalasis, lid blepharoplasty, orbital septum, upper eyelid, anesthesia, dermatochalasis, hemostasis

CHIEF COMPLAINT:, Leg pain.,HISTORY OF PRESENT ILLNESS:, This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol.,CURRENT MEDICATIONS:, Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,ALLERGIES:, Cipro, sulfa, Bactrim, and Demerol.,OBJECTIVE:,Vital Signs: Weight is 248 pounds which is a 12-pound drop from January. Blood pressure 120/70. Pulse 68.,General: This is a well-developed adult female, awake, alert, and in no acute distress.,HEENT: Oropharynx and HEENT are within normal limits.,Lungs: Clear.,Heart: Regular rhythm and rate.,Abdomen: Soft, nontender, and nondistended without organomegaly.,GU: Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,Neurologic: Deep tendon reflexes are normal.,Extremities: Pulses in lower extremities are normal. Straight leg lifts are normal.,ASSESSMENT/PLAN:,1. Leg pain/bone pain, I am going to check her CMP. I think this possibly is a side effect from Lipitor. We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time. Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects. We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2. Hypercholesterolemia, this is somewhat bothersome as she is a diabetic. Did discuss with her that we need to stick to the diet especially after going off of Lipitor. We will see how she does with her bone pain/leg pain off of Lipitor. If she has improvement may consider Crestor in one month. I am going to check her lipid panel and a CMP. Apparently, she is going to get this at a different site, Mapleridge in Wichita.,3. Type II diabetes. We will decrease her Glucovance because she is having frequent low blood sugars. Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms. I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment.soap / chart / progress notes, cmp, hypercholesterolemia, leg pain, type ii diabetes, ankle, blood sugars, bone pain, buttocks, pain, radiates from her buttocks, leg pain/bone, leg, sugars, weight,

PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:, Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:, None. The patient was taken to Postanesthesia Care Unit in stable condition. The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder. X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid. She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head. All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention. The patient still wanted to proceed forward with surgical intervention. The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table. The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. The patient was moved to a beach chair position. All extremities were well padded. Her head was well padded to the table. Her right upper extremity was draped in sterile fashion. A saber incision was made from the coracoid down to the axilla. Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case. Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made. Subscapularis tendon was released. The humeral head was brought in to; there were large osteophytes that were removed with an osteotome. The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region. A sizer was placed. It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin. This was placed, after which a reamer was placed along the humeral head and reamed to a size 5. All extra osteophytes were excised. The supraspinatus and infraspinatus tendons were intact. Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation. The arm had excellent range of motion. There are no signs of gross dislocation. Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head. Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position. After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction. There was no gross sign of dislocation. Wound site once again it was copiously irrigated with saline antibiotics. The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon. After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl. The skin was closed with staples. A sterile dressing was placed. The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.surgery, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,

CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. The patient does have a past medical history of diabetes and hypertension. In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. She has not had any musculoskeletal or neurological deficits. She denies any rashes or skin lesions.,PAST MEDICAL HISTORY: ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY: ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. In general, she is well developed, well nourished, oriented, and alert and in no apparent distress. Head, ears, eyes, nose, and throat are unremarkable. Neck is supple. No neck vein distention is noted. No bruits are heard. Chest is clear to percussion and auscultation. Heart has a regular rhythm and rate without murmurs or rubs or gallops. Abdomen is soft, obese, and nontender. Musculoskeletal is intact without deformity. However, the patient did develop severe cramp behind her left knee during her treadmill testing. Neurologic: Cranial nerves are intact and she is nonfocal. Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. Liver function panel is normal. CK was 82. MB fraction was 1.0. Troponin was less than 0.1 on three occasions. White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. EKG was normal.,DIAGNOSES ON ADMISSION:,1. Urinary tract infection.,2. Chest pain of unclear etiology, rule out myocardial infarction.,3. Neck and back pain of unclear etiology with a negative spinal tap.,4. Hypertension.,5. Diabetes type II, not treated with insulin.,6. Hyperlipidemia treated with TriCor but not statins.,7. Arthritis.,ADDITIONAL LABORATORY STUDIES:, B-natriuretic peptide was 26. Urine smear and culture negative on 24 and 48 hours. Chest x-ray was negative. Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications. This will be listed at the end of the discharge summary. She was put on rule out acute myocardial infarction routine, and she did in fact rule out. She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70. She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1. Enteric-coated aspirin 81 mg one daily. This is new, as the patient was not taking aspirin at home.,2. TriCor 48 mg one daily.,3. Zantac 40 mg one daily.,4. Lisinopril 20 mg one daily.,5. Mobic 75 mg one daily for arthritis.,6. Metformin 500 mg one daily.,7. Macrodantin one two times a day for several more days.,8. Zocor 20 mg one daily, which is a new addition.,9. Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:, As tolerated. Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week. Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.nan

PREOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,POSTOPERATIVE DIAGNOSIS: , Painful ingrown toenail, left big toe.,OPERATION: , Removal of an ingrown part of the left big toenail with excision of the nail matrix.,DESCRIPTION OF PROCEDURE: ,After obtaining informed consent, the patient was taken to the minor OR room and intravenous sedation with morphine and Versed was performed and the toe was blocked with 1% Xylocaine after having been prepped and draped in the usual fashion. The ingrown part of the toenail was freed from its bed and removed, then a flap of skin had been made in the area of the matrix supplying the particular part of the toenail. The matrix was excised down to the bone and then the skin flap was placed over it. Hemostasis had been achieved with a cautery. A tubular dressing was performed to provide a bulky dressing.,The patient tolerated the procedure well. Estimated blood loss was negligible. The patient was sent back to Same Day Surgery for recovery.podiatry, toenail, nail matrix, ingrown toenail, painful, ingrown,

EXAM: , Two views of the pelvis.,HISTORY:, This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY. Lateral view of the right hip was evaluated.,FINDINGS:, Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY. Current films reveal stable appearing post-surgical changes. Again demonstrated is a single intramedullary screw across the left femoral neck and head. There are 2 intramedullary screws through the greater trochanter of the right femur. There is a lucency along the previous screw track extending into the right femoral head and neck. There has been interval removal of cutaneous staples and/or surgical clips. These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1. Stable-appearing right hip joint status-post pinning.,2. Interval removal of skin staples as described above.orthopedic, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure were explained. She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery. General anesthesia was carried out without difficulty and a Foley catheter was inserted. The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion. A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope. Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum. A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region. The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized. The base of the cecum was acutely inflamed but not perforated. I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix. The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty. I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty. I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty. I reinserted the suprapubic port and irrigated out the right lower quadrant until dry. One final inspection revealed no bleeding from the staple line. We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites. The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture. The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture. Steri-strips and sterile dressings were applied. No complications. Minimal blood loss. Specimen is the appendix. Brought to the recovery room in stable condition.surgery, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,

BILATERAL SCROTAL ORCHECTOMY,PROCEDURE:,: The patient is placed in the supine position, prepped and draped in the usual manner. Under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision. Hemostasis was obtained with the Bovie and the spermatic cord was identified. It was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% Marcaine for postoperative pain relief. The left testicle was delivered through the same incision. The spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent Marcaine. The incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin. A dry sterile dressing fluff and scrotal support applied over that. The patient was sent to the Recovery Room in stable condition.surgery, scrotum, hemostasis, marcaine, catgut, incision, scrotal orchiectomy, spermatic cord, sterile dressing, testicle, transverse, suture ligated, chromic catgut, orchiectomy, scrotal, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

PROCEDURE PERFORMED:, Laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.,A 2 cm infraumbilical midline incision was made. The fascia was then cleared of subcutaneous tissue using a tonsil clamp. A 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident. Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening. Pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmHg.,The remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along Langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar. A total of 3 other trocars were placed. The first was a 10/11 mm trocar in the upper midline position. The second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine. The third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars. All of the trocars were placed without difficulty.,The patient was then placed in reverse Trendelenburg position and was rotated slightly to the left. The gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder. A laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of Calot were meticulously dissected free.,A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder. The gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips. Several attempts at passing the cholangiocatheter into the ductotomy were made. Despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct. After several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography. The distal cystic duct was doubly clipped. The duct was divided between the clips. The clips were carefully placed to avoid occluding the juncture with the common bile duct. The port sites were injected with 0.5% Marcaine.,The cystic artery was found medially and slightly posteriorly to the cystic duct. It was carefully dissected free from its surrounding tissues. A laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally. The artery was divided between the clips. The port sites were injected with 0.5% Marcaine.,After the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using Bovie electrocautery. Prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,After the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula. The neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm Hasson cannula. As the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen. The neck of the gallbladder was then secured with a Kocher clamp, and the gallbladder was removed from the abdomen.,Following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,Both midline fascial defects were then approximated using 0 Vicryl suture. All skin incisions were approximated with 4-0 Vicryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. Dressings were applied. All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.gastroenterology, intraoperative cholangiogram, cystic artery, laparoscopic cholecystectomy, cystic duct, gallbladder, tonsil, cholecystectomy, cholangiogram, abdomen, laparoscopic, cannula,

PREOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,POSTOPERATIVE DIAGNOSIS: , Left canal cholesteatoma.,OPERATIVE PROCEDURE:,1. Left canal wall down tympanomastoidectomy with ossicular chain reconstruction.,2. Microdissection.,3. NIM facial nerve monitoring for three hours.,COMPLICATIONS: ,None.,FINDINGS:, There is an extremely large canal cholesteatoma, which eroded most of the posterior and superior canal wall. There was a significant amount of myringosclerosis and tympanosclerosis. There is some mild erosion of the lenticular process of the incus. The facial nerve was normal. We removed the incus, removed the head of the malleus, and placed a titanium-PORP from the stapes capitulum to a cartilage graft.,PROCEDURE: , The patient was taken to the operating room, placed under general anesthetic and intubated without difficulty. The NIM facial nerve monitoring electrodes were positioned and monitoring was performed throughout the procedure. There was no abnormal activity during this case. We inspected the ear canal, identified the huge defect, which was completely filled with cerumen. Through the ear canal, we removed as much as we could and then infiltrated the canal and postauricular area with 1:100,000 of epinephrine.,We prepped and draped the ear in a sterile fashion. We reopened the previously used postauricular incision and dissected down the mastoid cortex. We reflected the soft tissues anteriorly to the level of the ear canal and identified where the ear canal skin entered the defect in the mastoid bone. A #6 cutting bur was used to drill down the mastoid cortex and identified this cholesteatoma which was then carefully dissected out. We went all the way to the mastoid antrum. We finished a complete mastoidectomy with identification of the tegmen, sigmoid sinus. We removed the lateral aspect of the mastoid tip. We lowered the facial ridge. The incudostapedial joint was already membranous in nature, we went ahead and used the joint knife and removed the incus. We separated the incus from the stapes and then removed it. We used a malleus head nipper to remove the head of the malleus and then we continued to saucerize the entire mastoid cavity.,There was no cholesteatoma within the middle ear space, but there was roughly 40% surface area perforation. The remaining portion of the tympanic membrane was extremely calcified and myringosclerotic; this was removed. There was also a large focus of tympanosclerosis between the stapes crura, which was impinging the ability of the stapes to move. We carefully dissected this out. This did seem to improve the mobility of the stapes somewhat. At this point, there was a near total perforation. There was only a minimal amount of anterior remnant of the drum left. We tried to go ahead and harvest the temporalis fascia, but there was really only wisps of this fascia in place. He had already had a previous tympanoplasty, but even outside the areas where the graft was taken, the temporalis muscle was quite atrophied and lumpy, and I suspect this was due to his chronic disease and long history of corticosteroid usage. We harvested a few pieces as best as we could. We went ahead and did a meatoplasty by making a canal incision in the 6 o'clock and 12 o'clock positions. We excised cartilage posteriorly and inferiorly to enlarge the meatus. This cartilage was thin and used for cartilage tympanoplasty. We placed some Gelfoam in the middle ear space and placed the cartilage on the top of it. We did cut a titanium-PORP of the proper side and placed on top of the stapes capitulum to interface with the cartilage cap. A few other small pieces of temporalis fascia were used to bulge through the surrounding edges of the cartilage and make sure that it was medial to any remnant of ear canal and tympanic membrane remnants. We placed a layer of Gelfoam lateral to the graft, closed the postauricular incision in layers and put 2 Merocel packs in the ear. Glasscock dressing was applied. The patient was awakened from anesthesia and taken to the recovery room in stable condition. He will be given antibiotics and pain medicines and he will be given instructions to follow up with me in one week.surgery, cholesteatoma, gelfoam, glasscock dressing, microdissection, nim, canal, canal wall, cerumen, facial nerve, incus, myringosclerosis, ossicular chain reconstruction, titanium-porp, tympanomastoidectomy, tympanosclerosis, facial nerve monitoring, ear canal, cartilage, ear,

CHIEF COMPLAINT:, Toothache.,HISTORY OF PRESENT ILLNESS: ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL: No fever or chills. No fatigue or weakness. No recent weight change. HEENT: No headache, no neck pain, the toothache pain for the past three days as previously mentioned. There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids. The patient denies any rhinorrhea. No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change. CARDIOVASCULAR: No chest pain. RESPIRATIONS: No shortness of breath or cough. GASTROINTESTINAL: No abdominal pain. No nausea or vomiting. GENITOURINARY: No dysuria. MUSCULOSKELETAL: No back pain. No muscle or joint aches. SKIN: No rashes or lesions. NEUROLOGIC: No vision or hearing change. No focal weakness or numbness. Normal speech. HEMATOLOGIC/LYMPHATIC: No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:, PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal. CONSTITUTIONAL: The patient is well nourished and well developed. The patient is a little overweight but otherwise appears to be healthy. The patient is calm, comfortable, in no acute distress, and looks well. The patient is pleasant and cooperative. HEENT: Eyes are normal with clear conjunctiva and cornea bilaterally. There is no icterus, injection, or discharge. Pupils are 3 mm and equally round and reactive to light bilaterally. There is no absence of light sensitivity or photophobia. Extraocular motions are intact bilaterally. Ears are normal bilaterally without any sign of infection. There is no erythema, swelling of canals. Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it. Nose is normal without rhinorrhea or audible congestion. There is no tenderness over the sinuses. NECK: Supple, nontender, and full range of motion. There is no meningismus. No cervical lymphadenopathy. No JVD. Mouth and oropharynx shows multiple denture and multiple dental caries. The patient has tenderness to tooth #12 as well as tooth #21. The patient has normal gums. There is no erythema or swelling. There is no purulent or other discharge noted. There is no fluctuance or suggestion of abscess. There are no new dental fractures. The oropharynx is normal without any sign of infection. There is no erythema, exudate, lesion or swelling. The buccal membranes are normal. Mucous membranes are moist. The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome. CARDIOVASCULAR: Heart is regular rate and rhythm without murmur, rub, or gallop. RESPIRATIONS: Clear to auscultation bilaterally without shortness of breath. GASTROINTESTINAL: Abdomen is normal and nontender. MUSCULOSKELETAL: No abnormalities are noted to back, arms and legs. The patient has normal use of his extremities. SKIN: No rashes or lesions. NEUROLOGIC: Cranial nerves II through XII are intact. Motor and sensory are intact to the extremities. The patient has normal speech and normal ambulation. PSYCHIATRIC: The patient is alert and oriented x4. Normal mood and affect. HEMATOLOGIC/LYMPHATIC: No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1. ODONTALGIA.,2. MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION: ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes. The patient was requested to have reevaluation within two days. The patient was given a prescription for Percocet and clindamycin. The patient was given drug precautions for the use of these medicines. The patient was offered discharge instructions on toothache but states that he already has it. He declined the instructions. The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

ADMITTING DIAGNOSIS:, Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:, Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1. Opioid use.,2. Right hip surgery.,3. Appendectomy.,4. Gastroesophageal reflux disease.,5. Hepatitis diagnosed by liver biopsy.,6. Blood transfusion.,6. Smoker.,7. Trauma with multiple orthopedic procedures.,8. Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:, Right total hip arthroplasty and removal of hardware.,CONSULTS:, Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:, For details, please refer to clinic notes and OP notes. In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head. She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware. After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications. She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning. DVT prophylaxis was initiated with Lovenox. Postop pain was adequately managed with the aid of Acute Pain team. Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin. Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:, Home. On the day of her discharge, she was afebrile, vital signs were stable. She was in no acute distress. Her right hip incision was clean, dry, and intact. Extremity was warm and well perfused. Compartments were soft. Capillary refill less than two seconds. Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed. Do not lift, drive, move furniture, do strenuous activity for six weeks. Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT: Follow up with Dr. X in two weeks.nan

PREOPERATIVE DIAGNOSES: ,1. Fractured and retained lumbar subarachnoid spinal catheter.,2. Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES: ,1. L1 laminotomy.,2. Microdissection.,3. Retrieval of foreign body (retained lumbar spinal catheter).,4. Attempted insertion of new external lumbar drain.,5. Fluoroscopy.,ANESTHESIA: , General.,HISTORY: ,The patient had a lumbar subarachnoid drain placed yesterday. All went well with the surgery. The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina. The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE: ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls. Her face was resting in a pink foam headrest. Extreme care was taken positioning her because she weighs 92 kg. There was a lot of extra padding for her limbs and her limbs were positioned comfortably. The arms were not hyperextended. Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance. A Foley catheter was in place. She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked. It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina. The incision was carried down through the fascia all the way down to the spinous processes. A self-retaining McCullough retractor was placed. The laminae were quite deep. The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura. The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors. At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right. The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus. Microdissection under high magnification did not expose the catheter. The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle. Dr. Y also tried. Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned. It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus. The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura. The paraspinous muscles were closed with 0 Vicryl interrupted sutures. The subcutaneous fascia was also closed with 0 Vicryl interrupted suture. The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide. The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room. The patient tolerated procedure well. No complications. Sponge and needle counts correct. Blood loss minimal, none replaced. This procedure took 5 hours. This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,

REASON FOR CONSULTATION:, Abnormal cardiac enzyme profile.,HISTORY OF PRESENT ILLNESS:, The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY: , Foot surgery as per the family members.,MEDICATIONS:,1. Vitamin supplementation.,2. Prednisone.,3. Cyclobenzaprine.,4. Losartan 50 mg daily.,5. Nifedipine 90 mg daily.,6. Lasix.,7. Potassium supplementation.,ALLERGIES:, SULFA.,PERSONAL HISTORY:, He is an ex-smoker. Does not consume alcohol.,PAST MEDICAL HISTORY: , Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile.,REVIEW OF SYSTEMS: , Limited.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting.,HEENT: Atraumatic and normocephalic.,NECK: Supple. Neck veins flat.,LUNGS: Air entry bilaterally clear, rales are scattered.,HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6.,ABDOMEN: Soft, nontender.,EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted.,LABORATORY AND DIAGNOSTIC DATA: , EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes.,IMPRESSION:,1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.,2. Septicemia, septic shock secondary to cellulitis of the leg.,3. Acute renal shutdown.,4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure.,RECOMMENDATIONS:,1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.,2. Aggressive medical management including dialysis.,3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.,4. Explained to patient's family in detail regarding condition which is critical which they are aware of.nan

FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:radiology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet

PREOPERATIVE DIAGNOSES:,1. Dysphagia.,2. Right parapharyngeal hemorrhagic lesion.,POSTOPERATIVE DIAGNOSES:,1. Dysphagia with no signs of piriform sinus pooling or aspiration.,2. No parapharyngeal hemorrhagic lesion noted.,3. Right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,PROCEDURE PERFORMED: ,Fiberoptic nasolaryngoscopy.,ANESTHESIA: , None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 93-year-old Caucasian male who was admitted to ABCD General Hospital on 08/07/2003 secondary to ischemic ulcer on the right foot. ENT was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to LMA intubation. The patient subsequently resolved with his dysphagia and workup of Speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway. This is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,PROCEDURE DETAILS: ,The patient was brought in the semi-Fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx. The scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx. The patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,Within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx. There were no signs of any obstruction. The epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions. The patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions. The scope was then pulled out and the patient tolerated the procedure well. At this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.surgery, parapharyngeal, dysphagia, sinus pooling, piriform, nasolaryngoscopy, fiberoptic, laryngoscope, nasopharynx, oropharynx, fiberoptic nasolaryngoscopy, hemorrhagic lesion, aspiration, cartilage, hypopharynx, lesion,

CC: ,Paraplegia.,HX:, This 32 y/o RHF had been performing missionary work in Jos, Nigeria for several years and delivered her 4th child by vaginal delivery on 4/10/97. The delivery was induced with Pitocin, but was otherwise uncomplicated. For the first 4 days post-partum she noted clear liquid diarrhea without blood and minor abdominal discomfort. This spontaneous resolved without medical treatment. The second week post-partum she had 4-5 days of sinusitis, purulent nasal discharge and facial pain. She was otherwise well until 5/4/97 when stationed in a more rural area of Nigeria, she noted a dull ache in both knees (lateral to the patellae) and proximal tibia, bilaterally. The pain was not relieved by massage and seemed more bothersome when seated or supine. She had no sensory loss at the time.,On 5/6/97, she awakened to pain radiating down her knees to her anterior tibia. Over the next few hours the pain radiated circumferentially around both calves, and involved the soles of her feet and posterior BLE to her buttocks. Rising from bed became a laborious task and she required assistance to walk to the bathroom. Ibuprofen provided minimal analgesia. By evening the sole of one foot was numb.,She awoke the next morning, 5/9/97, with "pins & needles" sensation in BLE up to her buttocks. She was given Darvocet for analgesia and took an airplane back to the larger city she was based in. During the one hour flight her BLE weakness progressed to a non-weight bearing state (i.e. she could not stand). Local evaluation revealed 3/3 proximal and 4/4 distal BLE weakness. She had a sensory level to her waist on PP and LT testing. She also had mild lumbar back pain. Local laboratory evaluation: WBC 12.7, ESR 10. She was presumed to have Guillain-Barre syndrome and was placed on Solu-Cortef 1000mg qd and Sandimmune IV IgG 12.0 g.,On 5/10/97, she was airlifted to Geneva, Switzerland. Upon arrival there she had total anesthesia from the feet up to the inguinal region, bilaterally. There was flaccid areflexic paralysis of BLE and she was unable to void or defecate. Straight catheterization of the bladder revealed a residual volume of 1000cc. On 5/12/ CSF analysis revealed: Protein 1.5g/l, Glucose 2.2mmol/l, WBC 92 (O PMNS, 100% Lymphocytes), RBC 70, Clear CSF, bacterial-fungal-AFB-cultures were negative. Broad spectrum antibiotics and Solu-Medrol 1g IV qd were started. MRI T-L-spine, 5/12/97 revealed an intradural T12-L1 lesion that enhanced minimally with gadolinium and was associated with spinal cord edema in the affected area. MRI Brain, 5/12/97, was unremarkable and showed no evidence of demyelinating disease. HIV, HTLV-1, HSV, Lyme, EBV, Malaria and CMV serological titers were negative. On 5/15/97 the Schistosomiasis Mekongi IFAT serological titer returned positive at 1:320 (normal<1:80). 5/12/97 CSF Schistosomiasis Mekongi IFAT and ELISA were negative. She was then given a one day course of Praziquantel 3.6g total in 3 doses; and started on Prednisone 60 mg po qd; the broad spectrum antibiotics and Solu-Medrol were discontinued.,On 5/22/97, a rectal biopsy was performed to evaluate parasite eradication. The result came back positive for ova and granulomata after she had left for UIHC. The organism was not speciated. 5/22/97 CSF schistosomiasis ELISA and IFAT titers were positive at 1.09 and 1:160, respectively. These titers were not known when she initially arrived at UIHC.,Following administration of Praziquantel, she regained some sensation in BLE but the paraplegia, and urinary retention remained.,MEDS:, On 5/24/97 UIHC arrival: Prednisone 60mg qd, Zantac 50 IV qd, Propulsid 20mg tid, Enoxaparin 20mg qd.,PMH:, 1)G4P4.,FHX:, unremarkable.,SHX: ,Missionary. Married. 4 children ( ages 7,5,3,6 weeks).,EXAM:, BP110/70, HR72, RR16, 35.6C,MS: A&O to person, place and time. Speech fluent and without dysarthria. Lucid thought process.,CN: unremarkable.,Motor: 5/5 BUE strength. Lower extremities: 1/1 quads and hamstrings, 0/0 distally.,Sensory: Decreased PP/LT/VIB from feet to inguinal regions, bilaterally. T12 sensory level to temperature (ice glove).,Coord: normal FNF.,Station/Gait: not done.,Reflexes: 2/2 BUE. 0/0 BLE. No plantar responses, bilaterally.,Rectal: decreased to no rectal tone. Guaiac negative.,Other: No Lhermitte's sign. No paraspinal hypertonicity noted. No vertebral tenderness.,Gen exam: Unremarkable.,COURSE:, MRI T-L-spine, 5/24/97, revealed a 6 x 8 x 25 soft tissue mass at the L1 level posterior to the tip of the conus medullaris and extending into the canal below that level. This appeared to be intradural. There was mild enhancement. There was more enhancement along the distal cord surface and cauda equina. The distal cord had sign of diffuse edema. She underwent exploratory and decompressive laminectomy on 5/27/97, and was retreated with a one day course of Praziquantel 40mg/kg/day. Praziquantel is reportedly only 80% effective at parasite eradication.,She continued to reside on the Neurology/Neurosurgical service on 5/31/97 and remained paraplegic.nan

HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms. I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems. He first mentioned that he has neck pain. He states that he has had this for at least 15 years. It is worse with movement. It has progressed very slowly over the course of 15 years. It is localized to the base of his neck and is sharp in quality. He also endorses a history of gait instability. This has been present for a few years and has been slightly progressively worsening. He describes that he feels unsteady on his feet and "walks like a duck." He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet. When I asked him to describe this in more detail, the numbness is actually restricted to his toes. Left is slightly more affected than the right. He denies any tingling or paresthesias. He also described that he is slowly losing control of his hands. He thinks that he is dropping objects due to weakness or incoordination in his hands. This has also been occurring for the past one to two years. He has noticed that buttoning his clothes is more difficult for him. He also does not have any numbness or tingling in the hands. He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome. He did not even mention this on the initial part of my history taking. When I asked him to describe this further, he states that he experiences a general exhaustion. He basically lays in bed all day everyday. I asked him if he was depressed, he states that he is treated for depression. He is unsure if this is optimally treated. As I just mentioned, he stays in bed almost all day long and does not engage in any social activities. He does not think that he is necessarily sad. His appetite is good. He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past. I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago. He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago. He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes. He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation. He also saw Dr. Z for neurosurgical consultation a couple of weeks ago. He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:, He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit drug use. He lives with his wife. He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolemia. He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion. He states that he was evaluated by a pulmonologist and had a normal evaluation. He has occasional night sweats. His hearing is poor. He occasionally develops bloody stools, which he attributes to his Crohn's disease. He also was diagnosed with sleep apnea. He does not wear his CPAP machine on a regular basis. He has a history of anemia. Otherwise, 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 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance: He is well appearing in no acute distress. He has somewhat of a flat affect.,Cardiovascular: He has a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.,Chest: The lungs are clear to auscultation bilaterally.,Skin: There are no rashes or lesions.,Musculoskeletal: He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status: His speech is fluent without dysarthria or aphasia. He is alert and oriented to name, place, and date. Attention, concentration, and fund of knowledge are intact. He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Visual fields are full. Optic discs are normal. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.,Motor: He has normal muscle bulk and tone. There is no atrophy. He has few fasciculations in his calf muscles bilaterally. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities. There is no action or percussion myotonia or paramyotonia.,Sensory: He has absent vibratory sensation at the left toe. This is diminished at the right toe. Joint position sense is intact. There is diminished sensation to light touch and temperature at the feet to the knees bilaterally. Pinprick is intact. Romberg is absent. There is no spinal sensory level.,Coordination: This is intact by finger-nose-finger or heel-to-shin testing. He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes: They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles. Plantar reflexes are flexor. There is no ankle clonus, finger flexors, or Hoffman's signs. He has crossed adductors bilaterally.,Gait and Stance: He has a slightly wide-based gait. He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk. He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08: Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal. Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast: Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08: Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue. His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves. He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial. He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy. He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea. Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1. I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2. I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3. I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4. I believe that he needs to undergo psychotherapy for his depression. It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist. The patient is very open about proceeding with this suggestion.,5. He does need to have his sleep apnea better controlled. He states that he is not compliant because the face mask that he uses does not fit him well. This should also be addressed.nan

PREOPERATIVE DIAGNOSIS:, Hammertoe deformity of the right second digit.,POSTOPERATIVE DIAGNOSIS: , Hammertoe deformity of the right second digit.,PROCEDURE PERFORMED: , Arthroplasty of the right second digit.,The patient is a 77-year-old Hispanic male who presents to ABCD Hospital for surgical correction of a painful second digit hammertoe. The patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe. The patient presents n.p.o. since mid night last night and consented to sign in the chart. H&P is complete.,PROCEDURE IN DETAIL:, After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position. Using Webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time. Restraining, a lap belt was then placed around the patient's abdomen while laying on the table. After adequate anesthesia was administered by the Department of Anesthesia, a local digital block using 5 cc of 0.5% Marcaine plain was used to provide local anesthesia. The foot was then prepped and draped in the normal sterile orthopedic manner. The foot was then elevated and Esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmHg. The foot was then brought down to the level of the table and stockinet was cut and reflected after the Esmarch bandage was removed. A wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,Then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup. Then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue. Care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin. This was performed with the combination of blunt and dull dissection. Care was taken to avoid proper digital arteries and neurovascular bundles as were identified. Attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint. The medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure. Following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an Adson-Brown pickup. It was elevated with fresh #15 blade. The tendon and capsule was reflected along with the periosteum from the underlying bone dorsally. Following this, the distal portion of the tendon was identified in a like manner. The tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone. The proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,Following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues. Then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected. Care was taken to avoid the deep flexor tendon. The head of the proximal phalanx was taken with the Adson-Brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology. The wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment. The digit was also noted to be in rectus alignment. Proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity. Then using a #3-0 Vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue. Then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin. The toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site. Following this, the incision was dressed using a sterile Owen silk soaked in saline and gentamicin. The toe was bandaged using 4 x 4s, Kling, and Coban. The tourniquet was deflated and immediate hyperemia was noted to the digits I through V of the right foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit where the patient was given postoperative surgical shoe. Total tourniquet time for the case was 30 minutes. While in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot. The patient was given pain medications of Tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain. The patient was also given prescription for cane to aid in ambulation. The patient will followup with Dr. X on Tuesday in his office for postoperative care. The patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit. The patient tolerated the procedure well and the anesthesia with no complications.surgery, hammertoe deformity, arthroplasty, digit, proximal interphalangeal joint, periosteal tissue, interrupted sutures, interphalangeal joint, proximal phalanx, proximal, painful, tourniquet, hammertoe, phalanx, head, incisional, tendon

EXAM: , OB Ultrasound.,HISTORY:, A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.radiology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation

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.neurosurgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter,

DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:, Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound. Deep veins were imaged at the level of the common femoral and popliteal veins. All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis. The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression. The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,

PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:, Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION: ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. The patient received a venogram documenting patency of the subclavian vein. Skin incision with blunt and sharp dissection. Electrocautery for hemostasis. The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. The leads were sequentially checked. Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. Pocket was irrigated with antibiotic solution. The pocket was packed with bacitracin-soaked gauze. This was removed during the case and then irrigated once again. The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION: , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.surgery, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular

PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty. The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline. The catheter was fixed to the skin with sutures. The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.surgery, thoracis, intravenous, central line insertion, empyema, catheter,

INDICATION: ,gastroenterology, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia,

CHIEF COMPLAINT:, Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:, Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:, None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:, He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC: He denies any chest pain or shortness of breath.,GI: As noted above.,GU: As noted above.,ENDOCRINE: He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT: Unremarkable.,NECK: Supple. There is no mass, adenopathy, or bruit.,CHEST: Normal excursion.,LUNGS: Clear to auscultation and percussion.,COR: Regular. There is no S3, S4, or gallop. There is no murmur.,ABDOMEN: Soft. It is nontender. There is no mass or organomegaly.,GU: Unremarkable.,RECTAL: Deferred.,EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean.,NEUROLOGIC: Without focal deficits. The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:, Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed.nan

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

EXAM:, MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:, Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla. Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction. There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease. There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size. There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy. There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan. This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution. No abnormal mass effect is identified. There are no findings to suggest active hydrocephalus. No abnormal extra-axial collection is identified. There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation. The region of the pituitary/optic chiasm grossly appears normal. The mastoids and paranasal sinuses are clear.,IMPRESSION:,1. No definite acute findings identified involving the brain.,2. There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes. There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3. Moderate to moderately advanced atrophy.radiology, severe headaches, chiari malformation, cerebral ischemic change, mri head without contrast, cerebellar hemisphere, superior portion, mri head, cerebellar, infarction, ischemic

PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1. Right colon cancer.,2. Ascites.,3. Adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions.,3. Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT: , 200 cc.,CRYSTALLOIDS GIVEN: , 2700 cc.,INDICATIONS FOR THIS PROCEDURE: ,The patient is a 53-year-old African-American female who presented with near obstructing lesion at the hepatic flexure. The patient underwent a colonoscopy which found this lesion and biopsies were taken proving invasive adenocarcinoma. The patient was NG decompressed preoperatively and was prepared for surgery. The need for removal of the colon cancer was explained at length. The patient was agreeable to proceed with the surgery and signed preoperatively informed consent.,PROCEDURE: , The patient was taken to the Operative Suite and placed in the supine position under general anesthesia per Anesthesia Department and NG and Foley catheters were placed preoperatively. She was given triple antibiotics IV. Due to her near obstructive symptoms, a formal ________ was not performed.,The abdomen was prepped and draped in the usual sterile fashion. A midline laparotomy incision was made with a #10 blade scalpel and subcutaneous tissues were separated with electrocautery down to the anterior abdominal fascia. Once divided, the intraabdominal cavity was accessed and bowel was protected as the rest of the abdominal wall was opened in the midline. Extensive fluid was seen upon entering the abdomen, ascites fluid, which was clear straw-colored and this was sampled for cytology. Next, the small bowel was retracted with digital exploration and there was a evidence of hepatic flexure, colonic mass, which was adherent to the surrounding tissues. With mobilization of the colon along the line of Toldt down to the right gutter, the entire ileocecal region up to the transverse colon was mobilized into the field. Next, a window was made 5 inches from the ileocecal valve and a GIA-75 was fired across the ileum. Next, a second GIA device was fired across the proximal transverse colon, just sparring the middle colic artery. The dissection was then carried down along the mesentry, down to the root of the mesentry. Several lymph nodes were sampled carefully, and small radiopaque clips were applied along the base of the mesentry. The mesentry vessels are hemostated and tied with #0-Vicryl suture sequentially, ligated in between. Once this specimen was submitted to pathology, the wound was inspected. There was no evidence of bleeding from any of the suture sites. Next, a side-by-side anastomosis was performed between the transverse colon and the terminal ileum. A third GIA-75 was fired side-by-side and GIA-55 was used to close the anastomosis. A patent anastomosis was palpated. The anastomosis was then protected with a #2-0 Vicryl #0-muscular suture. Next, the mesenteric root was closed with a running #0-Vicryl suture to prevent any chance of internal hernia. The suture sites were inspected and there was no evidence of leakage. Next, the intraabdominal cavity was thoroughly irrigated with sterile saline and the anastomosis was carried into the right lower gutter. Omentum was used to cover the intestines which appeared dilated and indurated from the near obstruction. Next, the abdominal wall was reapproximated and the fascial layer using a two running loop PDS sutures meeting in the middle with good approximation of both the abdominal fascia. Additional sterile saline was used to irrigate the subcutaneous fat and then the skin was closed with sequential sterile staples.,Sterile dressing was applied and the skin was cleansed and the patient was awakened from anesthesia without difficulty and extubated in the Operating Room and she was transferred to Recovery Room in stable condition and will be continued to be monitored on the Telemetry Floor with triple antibiotics and NG decompression.,surgery, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy,

PREPROCEDURE DIAGNOSIS:, Stab wound, left posterolateral chest.,POST PROCEDURE DIAGNOSIS: , Stab wound, left posterolateral chest.,PROCEDURE PERFORMED: , Closure of stab wound.,ANESTHESIA: , 1% lidocaine with epinephrine by local infiltration.,NARRATIVE: ,The wound was irrigated copiously with 500 mL of irrigation and closed in 1 layer with staples after locally anesthetizing with 1% lidocaine with epinephrine. The patient tolerated the procedure well without apparent complications.surgery, posterolateral chest, stab wound, lidocaine, epinephrine, infiltration, closure,

INDICATION:, Prostate Cancer.,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.,FINDINGS:, There is a focus of abnormal increased tracer activity overlying the right parietal region of the skull. The uptake in the remainder of the skeleton is within normal limits. The kidneys image normally. There is increased activity in the urinary bladder suggesting possible urinary retention.,CONCLUSION:,1. Focus of abnormal increased tracer activity overlying the right parietal region of the skull. CT scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2. There is probably some degree of urinary retention.,urology, prostate cancer, technetium, whole body, urinary retention, bone scan, radionuclide,

PRINCIPAL DIAGNOSES:,1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4. Diabetes.,5. Bipolar disorder.,6. Chronic muscle aches.,7. Chronic lower extremity edema.,8. ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1. Paxil 40 mg once daily.,2. Cozaar.,3. Xanax 1 mg four times a day.,4. Prozac 20 mg a day.,5. Lasix 40 mg a day.,6. Potassium 10 mEq a day.,7. Mirapex two tablets every night.,8. Allegra 60 mg twice a day.,9. Avandamet 4/1000 mg daily.,10. Nexium 20 mg a day.,11. NovoLog 25/50.,REVIEW OF SYSTEMS:, Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact.,LABORATORY DATA:, White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.,3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.,4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5. He is followed for his diabetes by his internist.,6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now.nan

CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:, BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed.orthopedic, sensory loss, lumbar puncture, peritrigonal region, centrum semiovale, mri brain, white matter, demyelinating disease, csf, demyelinating, mri, brain,

SUBJECTIVE:, The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains.,CURRENT MEDICATIONS:, The patient’s current medications are as outlined.,ALLERGIES TO MEDICATIONS:, Erythromycin.,REVIEW OF SYSTEMS:, Significant for problems with agitated depression. Her respiratory status is unchanged as noted above.,EXAMINATION:,General: The patient is in no acute distress.,Vital signs: Blood pressure is 152/80, pulse 80 and respiratory rate 16.,HEENT: Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.,Neck: Supple without palpable lymphadenopathy.,Chest: Chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,Cardiovascular: Distant heart tones. Regular rate and rhythm.,Abdomen: Soft and nontender.,Extremities: Without edema.,Oxygen saturation was checked today on room air, at rest it was 90%.,ASSESSMENT:,1. Chronic obstructive pulmonary disease/emphysema, severe but stable.,2. Mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. History of depression and schizophrenia.,PLAN:, At this point, I have recommended that she continue current respiratory medicine. I did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. I have recommended that she use it with activity and at night. I spoke with her about her living situation. Encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. Follow up evaluation is planned in Pulmonary Medicine Clinic in approximately three months or sooner if need be.cardiovascular / pulmonary, respiratory, copd, chronic obstructive pulmonary disease, pulmonary medicine clinic, depression, emphysema, followup, hypoxemia, oxygen, schizophrenia, oxygen saturation, pulmonary medicine, medicine clinic, chest, medicine, pulmonary,

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above. He was seen a few weeks ago for routine followup, and he was noted for microhematuria. Due to his history of kidney stone, renal ultrasound as well as IVP was done. He presents today for followup. He denies any dysuria, gross hematuria or flank pain issues. Last stone episode was over a year ago. No history of smoking. Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis. IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis. The calcification previously noted on the ureter appears to be outside the course of the ureter. Otherwise unremarkable. This is discussed.,IMPRESSION: ,1. A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP. The patient is asymptomatic. We have discussed surgical intervention versus observation. He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2. Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future. Urine sent for culture and sensitivity.,PLAN: , As above. The patient will follow up for cystoscopy, urine sent for cytology, continue hydration. Call if any concern. The patient is seen and evaluated by myself.consult - history and phy., intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound

1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2. The left atrium appears mildly dilated.,3. The right atrium and right ventricle appear normal.,4. The aortic root appears normal.,5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.,8. The pulmonary valve appears normal with trace pulmonary insufficiency.,9. There is no pericardial effusion or intracardiac mass seen.,10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,cardiovascular / pulmonary, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: ,The patient was brought to the operating room where tetracaine drops were instilled in the eye. The patient was then prepped and draped using standard procedure. An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus. This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber. The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc. A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps. The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco. This was aided by cracking the lens nucleus with McPherson forceps. The remaining cortex was removed from the eye with the I&A. The capsular bag was then polished with the I&A on capsular bag. The bag was inflated using viscoelastic and then the wound extended slightly with a keratome. A folding posterior chamber lens was inserted and rotated into position using McPherson forceps. The I&A was then placed in the eye again and the remaining viscoelastic removed. The wound was checked for watertightness and found to be watertight. TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,

REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use. The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago. The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over. The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago. The patient says he was depressed and agitated. He says he used cocaine by snorting and nitrous oxide but denies other drug usage. He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital. The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure. The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:, Substance abuse as per HPI. The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:, Seizures.,PAST SURGICAL HISTORY:, Shoulder injury.,SOCIAL HISTORY:, The patient lives alone in an apartment uses prior to sobriety 15 months ago. He was a binge drinker, although unable to provide detail about frequency of binges. The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:, None reported.,MEDICATIONS OUTPATIENT:, Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1. Gabapentin 300 mg q.8h.,2. Seroquel 100 mg p.o. q.h.s.,3. Seroquel 25 mg p.o. q.8h. p.r.n.,4. Phenergan 12.5 mg IV q.4h. p.r.n.,5. Acetaminophen 650 mg q.4h. p.r.n.,6. Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown. The patient shows psychomotor agitation and is somewhat irritable. The patient makes fair eye contact and is cooperative. He had answers my questions with "I do not know." Mood "depressed" and "agitated." Affect is irritable. Thought process logical and goal directed with thought content. He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. Insight and judgment are both fair. The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge. The patient is A&O x3.,ASSESSMENT:,AXIS I: Substance withdrawal, substance abuse, and substance dependence.,AXIS II: Deferred.,AXIS III: History of seizures.,AXIS IV: Lives alone and unemployed.,AXIS V: 55.,IMPRESSION:, The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety. The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1. Gabapentin 300 mg q.8h. for agitation and history of seizures.,2. Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult. Please call with further questions.nan

CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66. HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.nan

EXAM: , Cervical, lumbosacral, thoracic spine flexion and extension.,HISTORY: , Back and neck pain.,CERVICAL SPINE,FINDINGS: ,AP, lateral with flexion and extension, and both oblique projections of the cervical spine demonstrate alignment and soft tissue structures to be unremarkable.radiology, radiologic exam, ap, back, cervical, oblique views, alignment, disc space, extension, fixation, flexion, foramina, intervertebral, lateral views, lumbosacral, neck, neck pain, oblique, odontoid view, pain, physiologic, projections, spine, subluxation, thoracic, flexion and extension, thoracic spine, vertebral

HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids. He also has VACTERL association with hydrocephalus. As an infant, he underwent placement of a right modified central shunt. On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt. On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt. A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization. He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels. Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units. On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation. A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion. The patient then followed conservatively since that time. The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:, After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped. Cardiac catheterization was performed as outlined in the attached continuation sheets. Vascular entry was by percutaneous technique, and the patient was heparinized. Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava. This catheter was then exchanged for a 5-French VS catheter of a distal wire. Apposition of the right pulmonary artery over, which the wedge catheter was advanced. The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle. Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle. The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance. Left ventricular pressure was found to be suprasystemic. A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure. Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum. Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium. There was a disappearance of a mild waist prior to spontaneous tear of the balloon. The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve. A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste. Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle. Further attempts to cross tricuspid valve were thus abandoned. Attention was then directed to a Fontan fenestration. A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg. With less than 10% fall in calculated cardiac index. The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm. A 7-French flexor sheath was again advanced cross the fenestration. A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium. Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk. Once the stable device configuration was confirmed, device was released from the delivery catheter. Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized. The catheters and sheaths were removed and topical pressure applied for hemostasis. The patient was returned to the recovery room in satisfactory condition. There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal. Mixed venous saturation was low due to systemic arterial desaturation. There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow. The right pulmonary veins were fully saturated. Left pulmonary veins were not entered. There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration. Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery. Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg. Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta. Phasic ascending and descending aortic pressures were similar and normal. The calculated systemic flow was normal. Pulmonary flow was reduced to the QT-QS ratio of 0.7621. Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle. The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries. There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle. Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis. There was symmetric contrast flow to both pulmonary arteries. A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration. There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow. The branch pulmonaries appeared mildly hypoplastic. Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility. Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava. Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery. There was an increase in the systemic arterial pressures. Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%. The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921. Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow. An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries. A small degree of contrast returned to the heart.,INITIAL DIAGNOSES: ,1. Pulmonary atresia.,2. VACTERL association.,3. Persistent sinusoidal right ventricle to the coronary communications.,4. Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS: ,1. Systemic to pulmonary shunts.,2. Right bidirectional Glenn shunt.,3. Revision of the central shunt.,4. Ligation and division of patent ductus arteriosus.,5. Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6. Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES: ,1. Favorable Fontan hemodynamics.,2. Hypertensive right ventricle.,3. Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4. Patent Fontan fenestration.,CURRENT INTERVENTION: ,1. Balloon dilation tricuspid valve attempted and failed.,2. Occlusion of a Fontan fenestration.,MANAGEMENT: ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference. A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair. Further cardiologic care will be directed by Dr. X.nan

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis. There are no signs of acute trauma. The nose is normal to palpation and inspection externally without evidence of acute trauma. Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling. The tympanic membranes are without disruption or infection. Hearing intact bilaterally to normal level speech. Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation. The septum is without acute traumatic lesions or disruption. The turbinates are without abnormal swelling. There is no unusual rhinorrhea or bleeding. ,LIPS/TEETH/GUMS: ,The lips are without infection, mass lesion or traumatic lesions. The teeth are intact without obvious signs of infection. The gingivae are normal to palpation and inspection. ,OROPHARYNX: ,The oral mucosa is normal. The salivary glands are without swelling. The hard and soft palates are intact. The tongue is without masses or swelling with normal movement. The tonsils are without inflammation. The posterior pharynx is without mass lesion with good patent oropharyngeal airway.ent - otolaryngology, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future. He is a pleasant gentleman with a history of Wilson's disease. It has been treated with penicillamine. He was diagnosed with this at age 14. He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort. He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate. He was admitted there and observed. He converted to normal sinus rhythm spontaneously and so he required no further interventions. He was started on Lopressor, which he has tolerated well. An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement. Normal ejection fraction. No other significant valvular abnormality. He reported to physicians there that he had cirrhosis related to his Wilson's disease. Therefore hepatologist was consulted. There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt. His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control. He is in normal sinus rhythm as of my evaluation of him on 06/12/2008. He is tolerating his metoprolol and aspirin without any difficulty. I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman. His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case. Otherwise, I will look forward to hearing back from you regarding his evaluation. Thank you as always for your care of our patient.letters, atrial enlargement, wilson's disease, penicillamine,

CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm. No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities. No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:nan

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

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rectal bleeding. She was brought to the Hospital with some loose stool. She was found to be dehydrated. She was given IV fluid bolus, but then she started bleeding from G-tube site. There was some fresh blood coming out of the G-tube site. She was transferred to PICU. She is hypertensive. Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007. Right above knee amputation.,ALLERGIES:, None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:, Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. KUB showed large stool with dilated small and large bowel loops. Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1. Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL: She is intubated.,HEENT: Atraumatic. She is intubated.,LUNGS: Good air entry bilaterally. No rales or wheezing.,ABDOMEN: Distended. Decreased bowel sounds.,GENITALIA: Grossly normal female.,CNS: She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy. She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN: ,Plan is to give vitamin K, FFP, blood transfusion. Consider upper endoscopy. Procedure and informed consent discussed with the family.pediatrics - neonatal, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

PAST MEDICAL HISTORY: ,She had a negative stress test four to five years ago. She gets short of breath in walking about 30 steps. She has had non-insulin dependent diabetes for about eight years now. She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married. She is an office manager for a gravel company. Her spouse is also overweight. She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time. She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:, Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:, She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress. Alert and oriented x 3. HEENT: Normocephalic, atraumatic. Extraocular muscles intact, nonicteric sclerae. Chest is clear. Abdomen is obese, soft, nontender and nondistended. Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass. ABC will be asking for a letter of medical necessity from XYZ. She will also need an EKG and clearance for surgery. She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical

ADMISSION DIAGNOSES:,1. Pneumonia, failed outpatient treatment.,2. Hypoxia.,3. Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1. Atypical pneumonia, suspected viral.,2. Hypoxia.,3. Rheumatoid arthritis.,4. Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission. She was seen on multiple occasions at Urgent Care and in her physician's office. Initial x-ray showed some mild diffuse patchy infiltrates. She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin. Her O2 saturations drifted downward. They were less than 88% when active; at rest, varied between 88% and 92%. Decision was made because of failed outpatient treatment of pneumonia. Her medical history is significant for rheumatoid arthritis. She is on 20 mg of methotrexate every week as well as Remicade every eight weeks. Her last dose of Remicade was in the month of June. Hospital course was relatively unremarkable. CT scan was performed and no specific focal pathology was seen. Dr. X, pulmonologist was consulted. He also was uncertain as to the exact etiology, but viral etiology was most highly suspected. Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge. She was continued on Rocephin IV and azithromycin. Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status. She was instructed to finish azithromycin. She has two pills left at home. She is to follow up with Dr. X in two to three days. Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia. She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day). We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday. Methotrexate is known on some occasions to cause pneumonitis.discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,

PREOPERATIVE DIAGNOSIS:, Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:, Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out process was followed and preoperative antibiotics were given. The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected. An incision was made directly on the mass and carried down to the ribs. This is where the several chondral cartilages of the lower ribs meet. So I believe they were isolated in 9th rib anteriorly and I was able to encircle it. The medial area was __________. There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs. There was also a separate sharp growth of the mass growing superiorly. Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally. This may be due to an extension towards the inside of his chest. Hemostasis was revised. The internal mammary was intact and there was no obvious penetration of the pleural cavity. The specimen was sent to Pathology and then we proceeded to close the defect. Obviously, the space between the ribs cannot be approximated. So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well. Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.surgery, chest wall mass, local anesthetic, lower ribs, chest wall, mass, cartilages, wall, chest, ribs,

CT HEAD WITHOUT CONTRAST AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD WITHOUT CONTRAST,TECHNIQUE:, Noncontrast axial CT images of the head were obtained.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection. The ventricles and cortical sulci are normal in shape and configuration. The gray/white matter junctions are well preserved. There is no calvarial fracture. The visualized paranasal sinuses and mastoid air cells are clear.,IMPRESSION: , Negative for acute intracranial disease.,CT CERVICAL SPINE,TECHNIQUE: ,Noncontrast axial CT images of the cervical spine were obtained. Sagittal and coronal images were obtained.,FINDINGS:, Straightening of the normal cervical lordosis is compatible with patient position versus muscle spasms. No fracture or subluxation is seen. Anterior and posterior osteophyte formation is seen at C5-C6. No abnormal anterior cervical soft tissue swelling is seen. No spinal compression is noted. The atlanto-dens interval is normal. There is a large retention cyst versus polyp within the right maxillary sinus.,IMPRESSION:,1. Straightening of the normal cervical lordosis compatible with patient positioning versus muscle spasms.,2. Degenerative disk and joint disease at C5-C6.,3. Retention cyst versus polyp of the right maxillary sinus.neurology, muscle spasms, cervical lordosis, intracranial hemorrhage, motor vehicle collision, axial ct images, ct head, ct, anterior, cyst, polyp, maxillary, contrast, intracranial, sinuses, spine, axial, head, cervical, noncontrast

PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:, Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:, General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia. A #21-French cystourethroscope was inserted into the bladder. Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice. No other lesions were noted. Using a cold punch biopsy forceps, a random biopsy was obtained. The entire area was electrofulgurated using the Bugbee electrode. The patient tolerated the procedure well and left the operating room in satisfactory condition.urology, bladder neck, bladder tumors, cystoscopy, tur, electrofulguration, bladder

CHIEF COMPLAINT: , Congestion and cough.,HISTORY OF PRESENT ILLNESS: ,The patient is a 5-month-old infant who presented initially on Monday with a cold, cough, and runny nose for 2 days. Mom states she had no fever. Her appetite was good but she was spitting up a lot. She had no difficulty breathing and her cough was described as dry and hacky. At that time, physical exam showed a right TM, which was red. Left TM was okay. She was fairly congested but looked happy and playful. She was started on Amoxil and Aldex and we told to recheck in 2 weeks to recheck her ear. Mom returned to clinic again today because she got much worse overnight. She was having difficulty breathing. She was much more congested and her appetite had decreased significantly today. She also spiked a temperature yesterday of 102.6 and always having trouble sleeping secondary to congestion.,ALLERGIES: , She has no known drug allergies.,MEDICATIONS: ,None except the Amoxil and Aldex started on Monday.,PAST MEDICAL HISTORY: ,Negative.,SOCIAL HISTORY: , She lives with mom, sister, and her grandparent.,BIRTH HISTORY: , She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.,IMMUNIZATIONS: , Also up-to-date.,PAST SURGICAL HISTORY: , Negative.,FAMILY HISTORY: ,Noncontributory.,PHYSICAL EXAMINATION:,VITAL SIGNS: Her respiratory rate was approximately 60 to 65.,GENERAL: She was very congested and she looked miserable. She had no retractions at this time.,HEENT: Her right TM was still red and irritated with no light reflex. Her nasal discharge was thick and whitish yellow. Her throat was clear. Her extraocular muscles were intact.,NECK: Supple. Full range of motion.,CARDIOVASCULAR EXAM: She was tachycardic without murmur.,LUNGS: Revealed diffuse expiratory wheezing.,ABDOMEN: Soft, nontender, and nondistended.,EXTREMITIES: Showed no clubbing, cyanosis or edema.,LABORATORY DATA: ,Her chem panel was normal. RSV screen is positive. Chest x-ray and CBC are currently pending.,IMPRESSION AND PLAN: ,RSV bronchiolitis with otitis media. Admit for oral Orapred, IV Rocephin, nebulizer treatments and oxygen as needed.nan

TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left. The right side prepped and draped in the usual sterile fashion. Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and. The second just lateral to the umbilicus. Once this was clear, the Bactiseal catheter was then tunneled. This was connected to a Strata valve. The Strata valve was programmed to a setting of 1.01 and this was ensured. The small burr hole was then created. The area was then coagulated. Once this was completed, new Bactiseal catheter was then inserted. It was connected to the Strata valve. There was good distal flow. The distal end was then inserted into the peritoneal region via trocar. Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue. The right frontal incision was then opened. The Ommaya reservoir identified and removed. The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn. Once all the wounds were completed, dry sterile dressings were applied. The patient was then transported back to the ICU in stable condition intubated. Blood loss minimal. All sponge and needle counts were correct.surgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus,

On review of systems, the patient admits to hypertension and occasional heartburn. She undergoes mammograms every six months, which have been negative for malignancy. She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure. She has had negative PPD.,PAST MEDICAL HISTORY:, Hypertension.,PAST SURGICAL HISTORY:, Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore. She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation: She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:, Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP: 133/72nan

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.surgery, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein

CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS: ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days. He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS: ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS: Stable. HEENT: PERRLA. EOMI. Conjunctivae anicteric. Skull is normocephalic. He is not complaining of bruising. HEENT: TMs and canals are normal. There is no Battle sign. NECK: Supple. He has good range of motion. Spinal processes are normal to palpation. LUNGS: Clear. CARDIAC: Regular rate. No murmurs or rubs. EXTREMITIES: Left elbow is tender. He does not wish to move it at all. Shoulder and clavicle are within normal limits. Wrist is normal to inspection. He does have some pain to palpation. Hand has good capillary refill. He seems to have decreased sensation in all three dermatomes. He has moderately good abduction of all fingers. He has moderate opponens strength with his thumb. He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow. He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length. The proximal part looks like it is in good position. The distal part has about 6 mm of displacement. There is no significant angulation. The joint itself appears to be intact. The fracture line ends where it appears above the joint. I do not see any extra blood in the joint. I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X. He suggests we go ahead and splint him up and he will follow the patient up. At this point, it does not seem like there needs to be any surgical revision. The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied. There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go. Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with. They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1. Fracture of the humerus, spiral.,2. Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3. Psychiatric disorder, unspecified.,DISPOSITION: The patient will follow up as mentioned above. They can return here anytime as needed.

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.nan

Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General: Pleasant, brighter.,Vital signs: 117/78, 12, 56.,Abdomen: Soft, nontender. Bowel sounds normal.,ASSESSMENT AND PLAN:,1. Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2. CAD/angina. See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,gastroenterology, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,

CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS: , This is an 86-year-old female who is a patient of Dr. X, who was transferred from ABCD Home due to persistent abdominal pain, nausea and vomiting, which started around 11:00 a.m. yesterday. During evaluation in the emergency room, the patient was found to have a high amylase as well as lipase count and she is being admitted for management of acute pancreatitis.,PAST MEDICAL HISTORY:, Significant for dementia of Alzheimer type, anxiety, osteoarthritis, and hypertension.,ALLERGIES: , THE PATIENT IS ALLERGIC TO POLLENS.,MEDICATIONS: , Include alprazolam 0.5 mg b.i.d. p.r.n., mirtazapine 30 mg p.o. daily, Aricept 10 mg p.o. nightly, Namenda 10 mg p.o. b.i.d., Benicar 40 mg p.o. daily, and Claritin 10 mg daily p.r.n.,FAMILY HISTORY: , Not available.,PERSONAL HISTORY: ,Not available.,SOCIAL HISTORY: ,Not available. The patient lives at a skilled nursing facility.,REVIEW OF SYSTEMS: ,She has moderate-to-severe dementia and is unable to give any information about history or review of systems.,PHYSICAL EXAMINATION:,GENERAL: She is awake and alert, able to follow few simple commands, resting comfortably, does not appear to be in any acute distress.,VITAL SIGNS: Temperature of 99.5, pulse 82, respirations 18, blood pressure of 150/68, and pulse ox is 90% on room air.,HEENT: Atraumatic. Pupils are equal and reactive to light. Sclerae and conjunctivae are normal. Throat without any pharyngeal inflammation or exudate. Oral mucosa is normal.,NECK: No jugular venous distention. Carotids are felt normally. No bruit appreciated. Thyroid gland is not palpable. There are no palpable lymph nodes in the neck or the supraclavicular region.,HEART: S1 and S2 are heard normally. No murmur appreciated.,LUNGS: Clear to auscultation.,ABDOMEN: Soft, diffusely tender. No rebound or rigidity. Bowel sounds are heard. Most of the tenderness is located in the epigastric region.,EXTREMITIES: Without any pedal edema, normal dorsalis pedis pulsations bilaterally.,BREASTS: Normal.,BACK: The patient does not have any decubitus or skin changes on her back.,LABS DONE AT THE TIME OF ADMISSION: , WBC of 24.3, hemoglobin and hematocrit 15.3 and 46.5, MCV 89.3, and platelet count of 236,000. PT 10.9, INR 1.1, PTT of 22. Urinalysis with positive nitrite, 5 to 10 wbc's, and 2+ bacteria. Sodium 134, potassium 3.6, chloride 97, bicarbonate 27, calcium 8.8, BUN 25, creatinine 0.9, albumin of 3.4, alkaline phosphatase 109, ALT 121, AST 166, amylase 1797, and lipase over 3000. X-ray of abdomen shows essentially normal abdomen with possible splenic granulomas and degenerative spine changes. CT of the abdomen revealed acute pancreatitis, cardiomegaly, and right lung base atelectasis. Ultrasound of the abdomen revealed echogenic liver with fatty infiltration. Repeat CBC from today showed white count to be 21.6, hemoglobin and hematocrit 13.9 and 41.1, platelet count is normal, 89% segments and 2% bands. Sodium 132, potassium 4.0, chloride 98, bicarbonate 22, glucose 184, ALT 314, AST 382, amylase 918, and lipase 1331. The cultures are pending at this time. EKG shows sinus rhythm, rate about 90 per minute, multiple ventricular premature complexes are noted. Troponin 0.004 and myoglobin is 39.6.,ASSESSMENT:,1. Acute pancreatitis.,2. Leukocytosis.,3. Urinary tract infection.,4. Hyponatremia.,5. Dementia.,6. Anxiety.,7. History of hypertension.,8. Abnormal electrocardiogram.,9. Osteoarthrosis.,PLAN:, Admit the patient to medical floor, NPO, IV antibiotics, IV fluids, hold p.o. medications, GI consult, pain control, Zofran IV p.r.n., bedrest, DVT prophylaxis, check blood and urine cultures. I have left a message for the patient's son to call me back.nan

INDICATIONS FOR PROCEDURE:, This is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. CPK is already over 1000. There is ST elevation in leads II and aVF, as well as a Q wave. The chest pain is now gone, mild residual shortness of breath, no orthopnea. Cardiac monitor shows resolution of ST elevation lead III.,DESCRIPTION OF PROCEDURE:, Following sterile prep and drape of the right groin, installation of 1% Xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-French sheath inserted. ACT approximately 165 seconds on heparin. Borderline hypotension 250 mL fluid bolus given and nitroglycerin patch removed. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricular pressures and left ventriculography. Left pullback pressure. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. He tolerated the procedure well and was transported to the Cardiac Step-Down Unit in stable condition.,HEMODYNAMIC DATA:, Left ventricular end diastolic pressure elevated post A-wave at 25 mm of Mercury with no aortic valve systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is unremarkable. The left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. The first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. The second diagonal branch is unremarkable, as are the tiny distal diagonal branches. The intermediate branch is a small, normal vessel. The ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small AV sulcus circumflex branch.,II. Right coronary artery: The right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. There are luminal irregularities, less than 25%, within the proximal to mid vessel. Some contrast thinning is present in the distal RCA just before the bifurcation into posterior descending and posterolateral branches. A 25%, smooth narrowing at the origin of the posterior descending branch. Posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,III. Left ventriculogram: The left ventricle is normal in size. Ejection fraction estimated at 40 to 45%. No mitral regurgitation. Severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,DISCUSSION:, Recent inferior myocardial infarction with only minor contrast thinning distal RCA remaining on coronary angiography with resolution of chest pain and ST segment elevation. Left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). Left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,PLAN:, Medical treatment, including Plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.surgery, cpk, q wave, st elevation, french angio-seal, pigtail catheter, st segment, ejection fraction, wall motion, diagonal branch, posterior descending, coronary artery, catheterization, circumflex, rca, cardiac, st, elevation, ventricular, stenosis, artery, coronary, branch,

INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. The treatment planning process requires at least 4 hours of physician time. The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. Sequential CT scans are obtained and transferred to the treatment planning software. Extensive analysis occurs. The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. In addition, organs at risk are outlined. Doses are selected both for targets, as well as for organs at risk. Associated dose constraints are placed. Inverse treatment planning is then performed in conjunction with the physics staff. These are reviewed by the physician and ultimately performed only following approval by the physician. Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. This is performed in hopes of minimizing associated complications. The physician delineates the treatment type, number of fractions and total volume. During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.radiology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

PREOPERATIVE DIAGNOSIS:, Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Right inguinal hernia.,PROCEDURE:, Right inguinal hernia repair.,INDICATIONS FOR PROCEDURE: , This patient is a 9-year-old boy with a history of intermittent swelling of the right inguinal area consistent with a right inguinal hernia. The patient is being taken to the operating room for inguinal hernia repair.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. The patient's inguinal and scrotal area were prepped and draped in the usual sterile fashion. An incision was made in the right inguinal skin crease. The incision was taken down to the level of the aponeurosis of the external oblique, which was incised up to the level of the external ring. The hernia sac was verified and dissected at the level of the internal ring and a high ligation performed. The distal remnant was taken to its end and excised. The testicle and cord structures were placed back in their native positions. The aponeurosis of the external oblique was reapproximated with 3-0 Vicryl as well as the Scarpa's, the skin closed with 5-0 Monocryl and dressed with Steri-Strips. The patient was extubated in the operating room and taken back to the recovery room. The patient tolerated the procedure well.urology, inguinal skin crease, inguinal hernia repair, external oblique, hernia repair, inguinal hernia, inguinal, hernia,

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. She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES: ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION: ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,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. 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. If not she would require tracheostomy. 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. She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home. So, the patient is being prepared for discharge at this point. We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home. Dr. Y feels she could be discharged today and will have her return to see him in a week.general medicine, diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,

REASON FOR EXAM: , Dynamic ST-T changes with angina.,PROCEDURE:,1. Selective coronary angiography.,2. Left heart catheterization with hemodynamics.,3. LV gram with power injection.,4. Right femoral artery angiogram.,5. Closure of the right femoral artery using 6-French AngioSeal.,Procedure explained to the patient, with risks and benefits. The patient agreed and signed the consent form.,The patient received a total of 2 mg of Versed and 25 mcg of fentanyl for conscious sedation. The patient was draped and dressed in the usual sterile fashion. The right groin area infiltrated with lidocaine solution. Access to the right femoral artery was successful, okayed with one attempt with anterior wall stick. Over a J-wire, 6-French sheath was introduced using modified Seldinger technique.,Over the J-wire, a JL4 catheter was passed over the aortic arch. The wire was removed. Catheter was engaged into the left main. Multiple pictures with RAO caudal, AP cranial, LAO cranial, shallow RAO, and LAO caudal views were all obtained. Catheter disengaged and exchanged over J-wire into a JR4 catheter, the wire was removed. Catheter with counter-clock was rotating to the RCA one shot with LAO, position was obtained. The cath disengaged and exchanged over J-wire into a pigtail catheter. Pigtail catheter across the aortic valve. Hemodynamics obtained. LV gram with power injection of 36 mL of contrast was obtained.,The LV gram assessed followed by pullback hemodynamics.,The catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-French AngioSeal with no hematoma. The patient tolerated the procedure well with no immediate postprocedure complication.,HEMODYNAMICS: ,The aortic pressure was 117/61 with a mean pressure of 83. The left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmHg. The pullback across the aortic valve reveals zero gradient.,ANATOMY: ,The left main showed minimal calcification as well as the proximal LAD. No stenosis in the left main seen, the left main bifurcates in to the LAD and left circumflex.,The LAD was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was TIMI 3 flow in the LAD. The LAD gave off two early diagonal branches. The second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,Left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the PDA. The left circumflex was large and patent, 6.0 mm in diameter. All three obtuse marginal branches appeared to be with no significant stenosis.,The obtuse marginal branch, the third OM3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis. The PDA was wide, patent, with no focal stenosis.,The RCA was a small nondominant system with no focal stenosis and supplying the RV marginal.,LV gram showed that the LV EF is preserved with EF of 60%. No mitral regurgitation identified.,IMPRESSION:,1. Patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2. Nondominant right, which is free of atheromatous plaque.,3. Minimal plaque in the diagonal branch II, and the obtuse,marginal branch III, with no focal stenosis.,4. Normal left ventricular function.,5. Evaluation for noncardiac chest pain would be recommended.

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

CHIEF COMPLAINT:, Low back pain and right lower extremity pain. The encounter reason for today's consultation is for a second opinion regarding evaluation and treatment of the aforementioned symptoms.,HPI - LUMBAR SPINE:, The patient is a male and 39 years old. The current problem began on or about 3 months ago. The symptoms were sudden in onset. According to the patient, the current problem is a result of a fall. The date of injury was 3 months ago. There is no significant history of previous spine problems. Medical attention has been obtained through the referral source. Medical testing for the current problem includes the following: no recent tests. Treatment for the current problem includes the following: activity modification, bracing, medications and work modification. The following types of medications are currently being used for the present spine problem: narcotics, non-steroidal anti-inflammatories and muscle relaxants. The following types of medications have been used in the past: steroids. In general, the current spine problem is much worse since its onset.,PAST SPINE HISTORY:, Unremarkable.,PRESENT LUMBAR SYMPTOMS:, Pain location: lower lumbar. The patient describes the pain as sharp. The pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by flexion, lifting, twisting, activity, riding in a car and sitting. The pain is made better by laying in the supine position, medications, bracing and rest. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. Pain distribution: the lower extremity pain is greater than the low back pain. The patient's low back pain appears to be discogenic in origin. The pain is much worse since its onset.,PRESENT RIGHT LEG SYMPTOMS:, Pain location: S1 dermatome (see the Pain Diagram). The patient describes the pain as sharp. The severity of the pain ranges from none to severe. The pain is severe frequently. It is present intermittently and most of the time daily. The pain is made worse by the same things that make the low back pain worse. The pain is made better by the same things that make the low back pain better. Sleep alteration because of pain: wakes up after getting to sleep frequently and difficulty getting to sleep frequently. The patient's symptoms appear to be radicular in origin. The pain is much worse since its onset.,PRESENT LEFT LEG SYMPTOMS:, None.,NEUROLOGIC SIGNS/SYMPTOMS:, The patient denies any neurologic signs/symptoms. Bowel and bladder function are reported as normal.nan

PREOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,POSTOPERATIVE DIAGNOSES:,1. Left superficial femoral artery subtotal stenosis.,2. Arterial insufficiency, left lower extremity.,OPERATIONS PERFORMED:,1. Left lower extremity angiogram.,2. Left superficial femoral artery laser atherectomy.,3. Left superficial femoral artery percutaneous transluminal balloon angioplasty. ,4. Left external iliac artery angioplasty.,5. Left external iliac artery stent placement.,6. Completion angiogram.,FINDINGS: ,This patient was brought to the OR with a non-severe stenosis of the proximal left superficial femoral artery in the upper one-third of his thigh. He is also known to have severe calcific disease involving the entire left external iliac system as well as the common femoral and deep femoral arteries.,Our initial plan today was to perform an atherectomy with angioplasty and stenting of the left superficial femoral artery as necessary. However, whenever we started the procedure, it became clear that there was a severe stenosis of the left superficial femoral artery at its takeoff from the left common femoral artery. The area was severely calcified including the external iliac artery extending up underneath the left inguinal ligament. Indeed, this ultimately was dissected due to manipulation of sheath catheters and sheath through the area. Ultimately, this wound up being a much more complex case than initially anticipated.,Because of the above, we ultimately performed a laser atherectomy of the left superficial femoral artery, which then had to be angioplastied to obtain a satisfactory result. The completion angiogram showed that there was a dissection of the left external iliac artery, which precluded flow down into the left lower extremity. We then had to come up and perform angioplasty and stenting of the left external iliac artery as well as aggressively dilating the takeoff of the less superficial femoral artery from the common femoral artery.,The left superficial femoral artery was dilated with a 6-mm balloon.,The left external iliac artery and common femoral arteries were dilated with an 8-mm balloon.,A 2.5-mm ClearPath laser probe was used to initially arthrectomize and debulk the superficial femoral artery starting at its takeoff from the common femoral artery and extending down to the tight stenotic area in the upper one-third of the thigh. After the laser atherectomy was performed, the area still did not look good and so an angioplasty was then done, which looked good; however, as noted above, after we had dealt with the superficial femoral artery, we then had proximal inflow problems, which had to be dealt by angioplasty and stenting.,The patient had good dorsalis pedis pulses bilaterally upon completion.,The right common femoral artery was used for access in an up-and-over technique.,PROCEDURE: , With the patient in the supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in the sterile fashion.,The right common femoral artery was punctured percutaneously, and a #5-French sheath was initially placed. We used a pigtail catheter to go up and over the aortic bifurcation and placed a stiff Amplatz guidewire down into the left common femoral artery. We then heparinized the patient and placed a #7-French Raby sheath over the Amplatz wire. A selective left lower extremity angiogram was then done with the above-noted findings.,We then used a ClearPath 2.5-mm laser probe to laser the proximal superficial femoral artery. Because of the findings as noted above, this became more involved than initially hoped for. Once the laser atherectomy had been completed, the vessel still did not look good, so we used a 6-mm balloon to thoroughly dilate the area. Once that had been done, it looked good and we performed what we felt would be a completion angiogram only to find out that we had a more proximal problem precluding flow down into the left femoral artery.,Once that was discovered, we then had to proceed with angioplasty and stenting of the left external iliac artery right down to the acetabular level.,Once we had dealt with our run-on problems, we then did another completion angiogram, which showed a good flow through the entire area and down into the left lower extremity.,Following completion of the above, all wires, sheaths, and catheters were removed from the right common femoral artery. Firm pressure was held over the puncture site for 20 minutes followed by application of a sterile Coverlet dressing and a firm pressure dressing.,The patient tolerated the procedure well throughout. He had good palpable dorsalis pedis pulses bilaterally on completion. He was taken to the recovery room in satisfactory condition. Protamine was given to partially reverse the heparin.nan

ADMITTING DIAGNOSES:, Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4. During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS: ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed. A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty. Plan was to remove the stent. At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement. He has had no recent cold or flu. He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies. Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:, A 14-organ system review of systems is negative except for the history of present illness. He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:, Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL: The patient is an active little boy.,HEENT: The head and neck exam was grossly normal. He had no oral, ocular, or nasal discharge.,LUNGS: Exam was normal without wheezing.,HEART: Without murmur or gallops.,ABDOMEN: Soft, without mass or tenderness with a well-healed flank incision.,GU: Uncircumcised male with bilaterally descended testes.,EXTREMITIES: He has full range of motion in all 4 extremities.,SKIN: Warm, pink, and dry.,NEUROLOGIC: Grossly intact.,BACK: He has normal back. Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy. He was made NPO. He had a fever at first time with elevated creatinine. He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure. Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty. He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy. The patient had draining nephrostomy tube without difficulty.,nan

SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1.,CHEST: Examination of the chest is clear to auscultation.,CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated.,ABDOMEN: Benign. Right renal angle is tender. Bowel sounds are positive.,EXTREMITIES: There is no swelling.,NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5. Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000. BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1. Sepsis due to urinary tract infection. Urine culture shows Escherichia coli, resistant to Levaquin. We changed to doripenem.,2. Urinary tract infection, we will treat with doripenem, change Foley catheter,3. Hypotension. Resolved, continue intravenous fluids.,4. Ischemic cardiomyopathy. No evidence of decompensation, we with monitor.,5. Diabetes type 2. Uncontrolled. Continue insulin sliding scale.,6. Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7. History of coronary artery disease. Troponin indeterminate. Cardiologist intends no further workup. Continue medical treatment. Most likely troponin is secondary to impaired clearance.general medicine, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION: ,1. The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2. Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily. She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention. All questions answered.soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence,

PROCEDURE:, Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1. GERD, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered. The oropharynx was sprayed with Cetacaine. The endoscope was passed, under direct visualization, into the esophagus. The squamocolumnar junction was irregular and edematous. Biopsies were obtained for histology. There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma. The entire gastric mucosa was normal, including a retroflexed view of the fundus. The entire duodenal mucosa was normal to the second portion. The patient tolerated the procedure well without complication.,IMPRESSION:,1. Gastroesophageal reflux disease, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies. The patient was told to continue maintenance Aciphex and anti-reflux precautions. He will follow up with me on a p.r.n. basis.gastroenterology, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. The benefits are ease of care and cleanliness and fewer urinary tract infections. The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE: ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner. Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed. Dorsal hemostasis was established and a dorsal slit was made. The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed. The infant was fitted with a XX-cm Plastibell. The foreskin was retracted around the Plastibell and circumferential hemostasis was established. The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss. Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.pediatrics - neonatal, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

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

PREOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1. Herniated disc, C5-C6.,2. Cervical spondylosis, C5-C6.,PROCEDURES,1. Anterior cervical discectomy with decompression, C5-C6.,2. Anterior cervical fusion, C5-C6.,3. Anterior cervical instrumentation, C5-C6.,4. Allograft C5-C6.,ANESTHESIA: ,General endotracheal.,COMPLICATIONS:, None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. Nonoperative measures failed to relieve her symptoms and surgical intervention was requested. We discussed reasonable risks, benefits, and alternatives of various treatment options. Continuation of nonoperative care versus the risks associated with surgery were discussed. She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. General anesthetic was administered. The patient was placed in the supine position. All prominences and neurovascular structures were well accommodated. The patient was noted to have pulse in this position. Preoperative x-rays revealed appropriate levels for skin incision. Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed. The patient was then prepped and draped in sterile fashion. Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease. Subcutaneous tissue was dissected down to the level of the omohyoid which was transected. Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. This was taken down to the prevertebral fascia which was bluntly split. Intraoperative x-ray was taken to ensure proper levels. Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. Inferior spondylosis was removed with high-speed bur. A scalpel and curette was used to remove the disc. Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. Disc herniation was removed from the right posterolateral aspect of the interspace. High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. No further evidence of compression was identified. Hemostasis was achieved with thrombin-soaked Gelfoam. Interspace was then distracted with Caspar pin distractions set gently. Interspace was then gently retracted with the Caspar pin distraction set. An 8-mm allograft was deemed in appropriate fit. This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. The graft was stable to pull-out forces. Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws. Plate and screws were then locked to the plate. Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. Wounds were copiously irrigated with normal saline. Omohyoid was approximated with 3-0 Vicryl. Running 3-0 Vicryl was used to close the platysma. Subcuticular Monocryl and Steri-Strips were used to close the skin. A deep drain was placed prior to wound closure. The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. There were no intraoperative complications. All needle and sponge counts were correct. Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.orthopedic, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy

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

PREOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,POSTOPERATIVE DIAGNOSES,1. Bowel obstruction.,2. Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction. She was being fed through a central line, which as per the patient was just put yesterday and this slipped out. At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion. Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty. A Seldinger technique was used and a triple-lumen catheter was inserted. There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.gastroenterology, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction