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preoperative diagnosis:, closed displaced probable pathological fracture, basicervical femoral neck, left hip.,postoperative diagnosis: , closed displaced probable pathological fracture, basicervical femoral neck, left hip.,procedures performed:,1. left hip cemented hemiarthroplasty.,2. biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment.,implants used:,1. depuy ultima calcar stem, size 3 x 45.,2. bipolar head 28 x 43.,3. head with +0 neck length.,4. distal centralizer and cement restrictor.,5. smartset antibiotic cement x2.,anesthesia: , general.,needle and sponge count: , correct.,complications: ,none.,estimated blood loss: , 300 ml.,specimen: , resected femoral head and tissue from the fracture site as well as the marrow from the canal.,findings: ,on exposure, the fracture was noted to be basicervical pattern with no presence of calcar about the lesser trochanter. the lesser trochanter was intact. the fracture site was noted to show abnormal pathological tissue with grayish discoloration. the quality of the bone was also pathologically abnormal with soft trabecular bone. the abnormal pathological tissues were sent along with the femoral head to pathology for assessment. articular cartilage of the acetabulum was intact and well preserved.,indication: , the patient is a 53-year-old female with a history of malignant melanoma, who apparently had severe pain in her left lower extremity and was noted to have a basicervical femoral neck fracture. she denied any history of fall or trauma. the presentation was consistent with pathological fracture pending tissue assessment. indication, risks, and benefits were discussed. treatment options were reviewed. no guarantees have been made or implied.,procedure: ,the patient was brought to the operating room and once an adequate general anesthesia was achieved, she was positioned on a pegboard with the left side up. the left lower extremity was prepped and draped in a standard sterile fashion. time-out procedure was called. antibiotics were infused.,a standard posterolateral approach was made. subcutaneous dissection was performed and the dissection was carried down to expose the fascia of the gluteus maximus. this was then incised along the line of the incision. hemostasis was achieved. charnley retractor was positioned. the trochanter was intact. the gluteus medius was well protected with retractor. the piriformis and minimus junction was identified. the minimus was also reflected along with the medius. using bovie and knife, the piriformis and external rotators were detached from its trochanteric insertion. similarly, l-shaped capsulotomy was performed. a #5 ethibond was utilized to tag the piriformis and the capsule for late repair. fracture site was exposed. the femoral neck fracture was noted to be very low-lying basicervical type. femoral head was retrieved without any difficulty with the help of a corkscrew. the head size was measured to be 43 mm. bony fragments were removed. the acetabular socket was thoroughly irrigated. a 43-mm bipolar trial head was inserted and this was noted to give a satisfactory fit with good stability. the specimens submitted to pathology included the resected femoral head and the tissue at the fracture site, which was abnormal with grayish discoloration. this was sent to the pathology. the fracture was noted to be basicervical and preoperatively, decision was made to consider cemented calcar stem. an l-shaped osteotomy was performed in order to accept the calcar prosthesis. the basicervical fracture was noted to be just at the level of superior border of the lesser trochanter. there was no calcar superior to the lesser trochanter. the l-shaped osteotomy was performed to refine the bony edges and accept the calcar prosthesis. hemostasis was achieved. now, the medullary canal was entered with a canal finder. the fracture site was well exposed. satisfactory lateralization was performed. attention was for the reaming process. using a size 1 reamer, the medullary canal was entered and reamed up to size 3, which gave us a satisfactory fit into the canal. at this point, a trial prosthesis size 3 with 45 mm calcar body was inserted. appropriate anteversion was positioned. the anteversion was marked with a bovie to identify subsequent anteversion during implantation. the bony edges were trimmed. the calcar implant with 45 mm neck length was fit in the host femur very well. there was no evidence of any subsidence. at this point, trial reduction was performed using a bipolar trial head with 0 neck length. the relationship between the central femoral head and the greater trochanter was satisfactory. the hip was well reduced without any difficulty. the stability and range of motion in extension and external rotation as well as flexion-adduction, internal rotation was satisfactory. the shuck was less than 1 mm. leg length was satisfactory in reference to the contralateral leg. stability was satisfactory at 90 degrees of flexion and hip at 75-80 degrees of internal rotation. similarly, keeping the leg completely adducted, i was able to internally rotate the hip to 45 degrees. after verifying the stability and range of motion in all direction, trial components were removed. the canal was thoroughly irrigated and dry sponge was inserted and canal was dried completely. at this point, 2 batches of smartset cement with antibiotics were mixed. the definitive ultima calcar stem size 3 with 45 mm calcar body was selected. centralizer was positioned. the cement restrictor was inserted. retrograde cementing technique was applied once the canal was dried. using cement gun, retrograde cementing was performed. the stem was then inserted into cemented canal with appropriate anteversion, which was maintained until the cement was set hard and cured. the excess cement was removed with the help of a curette and freer elevator. all the cement debris was removed.,attention was now placed for the insertion of the trial femoral head. once again, 0 neck length trial bipolar head was inserted over the trunnion. it was reduced and range of motion and stability was satisfactory. i also attempted with a -3 trial head, but the 0 gave us a satisfactory stability, range of motion, as well as the length and the shuck was also minimal. the hip was raised to 90 degrees of flexion and 95 degrees of internal rotation. there was no evidence of any impingement on extension and external rotation as well as flexion-adduction, internal rotation. i also tested the hip at 90 degrees of flexion with 10 degrees adduction and internal rotation and further progressive flexion of the hip beyond 90 degrees, which was noted to be very stable. at this point, a definitive component using +0 neck length and bipolar 43 head were placed over the trunnion and the hip was reduced. range of motion and stability was as above. now, the attention was placed for the repair of the capsule and the external rotators and the piriformis. this was repaired to the trochanteric insertion using #5 ethibond and suture plaster. satisfactory reinforcement was achieved with the #5 ethibond. the wound was thoroughly irrigated. hemostasis was achieved. the fascia was closed with #1 vicryl followed by subcutaneous closure using 2-0 vicryl. the wound was thoroughly washed and a local injection with mixture of morphine and toradol was infiltrated including the capsule and the pericapsular structures. skin was approximated with staples. sterile dressings were placed. abduction pillow was positioned and the patient was then extubated and transferred to the recovery room in a stable condition. there were no intraoperative complications noted.

chief complaint:,1. stage iiic endometrial cancer.,2. adjuvant chemotherapy with cisplatin, adriamycin, and abraxane.,history of present illness: , the patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009. in march 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus. ct scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis. on 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy. the pathology was positive for grade iii endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion. four of 30 lymph nodes were positive for disease. the left ovary was positive for metastatic disease. postsurgical pet/ct scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease. the patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup. of note, we had sent off genetic testing which was denied back in june. i have been trying to get this testing completed.,current medications: , synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,allergies:

endovascular brachytherapy (ebt),the patient is to undergo a course of angioplasty for in-stent restenosis. the radiotherapy will be planned using simulation films when the novoste system catheter markers are placed on either side of the coronary artery injury site. after this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter. the rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy. the does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter. given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for st segment elevation and correct machine function.

subjective:, this 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. it cleared for awhile. this has been an intermittent problem. now it is back again on his right lower abdomen. at first, it was thought that he may have early zoster. this started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. he has had no treatment on this; there are no skin changes at all. the patient bathes everyday but tries to use little soap. the patient is married. he works as an airplane mechanic.,family, social, and allergy history:, the patient has sinus and cva. he is a nonsmoker. no known drug allergies.,current medications:, lipitor, aspirin, folic acid.,physical examination:, the patient is well developed, appears stated age. overall health is good. he does have psoriasis with some psoriatic arthritis, and his skin looks normal today. on his trunk, he does have the hyperesthesia. as you touch him, he winces.,impression:, hyperesthesia, question etiology.,treatment:,1. discussed condition and treatment with the patient.,2. discontinue hot soapy water to these areas.,3. increase moisturizing cream and lotion.,4. i referred him to dr. abc or dr. xyz for neurology evaluation. we did not see anything on skin today. return p.r.n. flare.

chief complaint: , mental changes today.,history of present illness: , this patient is a resident from mazatlan, mexico, visiting her son here in utah, with a history of diabetes. she usually does not take her meal on time, and also not having her regular meals lately. the patient usually still takes her diabetic medication. today, the patient was found to have decrease in mental alertness, but no other gi symptoms. some sweating and agitation, but no fever or chills. no other rash. because of the above symptoms, the patient was treated in the emergency department here. she was found to glucose in 30 range, and hypertension. there was some question whether she also take her blood pressure medication or not. because of the above symptoms, the patient was admitted to the hospital for further care. the patient was given labetalol iv and also norvasc blood pressure, and also some glucose supplement. at this time, the patient's glucose was in the 175 range.,past medical history: , diabetes, hypertension.,past surgical history:, none.,family history: , unremarkable.,allergies: , no known drug allergies.,medications:, in spanish label. they are the diabetic medication, and also blood pressure medication. she also takes aspirin a day.,social history: ,the patient is a mazatlan, mexico resident, visiting her son here.,physical examination:,general: the patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,heent: clear, atraumatic, normocephalic. no sinus tenderness. no obvious head injury or any laceration. extraocular movements are intact. dry mucosal linings.,heart: regular rate and rhythm, without murmur. normal s1, s2.,lungs: clear. no rales. no wheeze. good excursion.,abdomen: soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,extremities: no edema, clubbing, or cyanosis. no rash.,laboratory findings: , on admission: cpk, troponin are negative. cmp is remarkable for glucose of 33. bmp is remarkable for bun of 60, creatinine is 4.3, potassium 4.7. urinalysis shows specific gravity of 10.30. ct of the brain showed no hemorrhage. chest x-ray showed no acute cardiomegaly or any infiltrates.,impression:,1. hypoglycemia due to not eating her meals on a regular basis.,2. hypertension.,3. renal insufficiency, may be dehydration, or diabetic nephropathy.,plan: , admit the patient to the medical ward, iv fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.

2-d echocardiogram,multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. cardiac function is normal. there is no significant chamber enlargement or hypertrophy. there is no pericardial effusion or vegetations seen. doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. pulmonary outflow is normal at the valve. pulmonary venous return is to the left atrium. the interatrial septum is intact. mitral inflow and ascending aorta flow are normal. the aortic valve is trileaflet. the coronary arteries appear to be normal in their origins. the aortic arch is left-sided and patent with normal descending aorta pulsatility.

reason for visit: , mr. abc is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. he returns today to review his response to cpap.,history of present illness: , the patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. he was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal cpap at 10 cm h2o nasal pressure. he has been on cpap now for several months, and returns for followup to review his response to treatment.,the patient reports that the cpap has limited his snoring at night. occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. the patient estimates that he uses the cpap approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night.,the patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. on weekends, he might sleep until 8 to 9 a.m. on saturday night, he might go to bed approximately mid night.,as noted, the patient is not snoring on cpap. he denies much tossing and turning and does not awaken with the sheets in disarray. he awakens feeling relatively refreshed.,in the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures.,he continues to work at smith barney in downtown baltimore. he generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. he is involved in training purpose to how to sell managed funds and accounts.,the patient reports no change in daytime stamina. he has no difficulty staying awake during the daytime or evening hours.,the past medical history is notable for allergic rhinitis.,medications: , he is maintained on flonase and denies much in the way of nasal symptoms.,allergies: , molds.,findings: ,vital signs: blood pressure 126/75, pulse 67, respiratory rate 16, weight 172 pounds, height 5 feet 9 inches, temperature 98.4 degrees and sao2 is 99% on room air at rest.,the patient has adenoidal facies as noted previously.,laboratories: the patient forgot to bring his smart card in for downloading today.,assessment: , moderate-to-severe sleep apnea. i have recommended the patient continue cpap indefinitely. he will be sending me his smart card for downloading to determine his cpap usage pattern. in addition, he will continue efforts to maintain his weight at current levels or below. should he succeed in reducing further, we might consider re-running a sleep study to determine whether he still requires a cpap.,plans: , in the meantime, if it is also that the possible nasal obstruction is contributing to snoring and obstructive hypopnea. i have recommended that a fiberoptic ent exam be performed to exclude adenoidal tissue that may be contributing to obstruction. he will be returning for routine followup in 6 months.

exam: , ct pelvis with contrast and ct abdomen with and without contrast.,indications: ,abnormal liver enzymes and diarrhea.,technique: , ct examination of the abdomen and pelvis was performed after 100 ml of intravenous contrast administration and oral contrast administration. pre-contrast images through the abdomen were also obtained.,comparison: ,there were no comparison studies.,findings: ,the lung bases are clear.,the liver demonstrates mild intrahepatic biliary ductal dilatation. these findings may be secondary to the patient's post cholecystectomy state. the pancreas, spleen, adrenal glands, and kidneys are unremarkable.,there is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. there are numerous nonspecific retroperitoneal and mesenteric lymph nodes. these may be reactive; however, an early neoplastic process would be difficult to totally exclude.,there is a right inguinal hernia containing a loop of small bowel. this may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. the large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,there is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,the urinary bladder is unremarkable. the uterus is not visualized.,impression:,1. right inguinal hernia containing small bowel. partial obstruction is suspected.,2. nonspecific retroperitoneal and mesenteric lymph nodes.,3. thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. diverticulosis without evidence of diverticulitis.,5. status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. osteopenia and degenerative changes of the spine and pelvis.

preoperative diagnosis:,1. left chronic anterior and posterior ethmoiditis.,2. left chronic maxillary sinusitis with polyps.,3. left inferior turbinate hypertrophy.,4. right anterior and posterior chronic ethmoiditis.,5. right chronic maxillary sinusitis with polyps.,6. right chronic inferior turbinate hypertrophic.,7. intranasal deformity causing nasal obstruction due to septal deviation.,postoperative diagnosis:,1. left chronic anterior and posterior ethmoiditis.,2. left chronic maxillary sinusitis with polyps.,3. left inferior turbinate hypertrophy.,4. right anterior and posterior chronic ethmoiditis.,5. right chronic maxillary sinusitis with polyps.,6. right chronic inferior turbinate hypertrophic.,7. intranasal deformity causing nasal obstruction due to septal deviation.,name of operation: , bilateral endoscopic sinus surgery, including left anterior and posterior ethmoidectomy, left maxillary antrostomy with polyp removal, left inferior partial turbinectomy, right anterior and posterior ethmoidectomy, right maxillary antrostomy and polyp removal, right partial inferior turbinectomy, and septoplasty.,anesthesia:, general endotracheal.,estimated blood loss: , approximately 20 cc.,history of present illness: , the patient is a 55-year-old female who has had chronic nasal obstruction secondary to nasal polyps and chronic sinusitis. she also has a septal deviation mid posterior to the left compromising greater than 70% of her nasal airway.,procedure: ,the patient was brought to the operating room and placed in the supine position. after adequate endotracheal anesthesia was obtained, the skin was prepped and draped in sterile fashion. lidocaine 1% with 1:100,000 epinephrine was injected into the region of the anterior portion of the nasal septum. approximately 10 cc total was used.,a #15 blade and the freer elevator were used to help make a standard hemitransfixion incision. a mucoperichondrial flap was carefully elevated, and the junction with the cartilaginous bony septum was separated with the freer elevator. the bony deflection was removed using jansen-middleton forceps. the cartilaginous deflection was created by freeing up the inferior attachments to the cartilaginous septum, placing it more on the midline maxillary crest. the initial incision was placed in its anatomical position and secured with a 4-0 nylon suture for stabilization effect.,attention then was directed toward the left side. lidocaine 1% with 1:100,000 epinephrine was injected in the region of the anterior portion of the left middle turbinate and uncinate process and polyps. approximately 10 cc total was used. the polyps were removed using the richards essential shaver to help identify the middle turbinate and uncinate process better. the uncinate process was removed systematically superiorly to inferiorly with back-biting forceps. next, the maxillary antrostomy was identified and expanded with the back-biting forceps and showed polypoid accumulation in the mucosal disease on its opening site. the sinus linings were edematous but did not have any polyps in the inferior, lateral, or superior aspects.,the anterior and posterior ethmoid air cells were entered primarily and dissected with the richards essential shaver followed by the use of a 30-degree endoscope and up-biting forceps for the superior and lateral dissection. bright mucosal disease and small polypoid accumulations were noted through the sinuses also. the inferior turbinates had some polypoid changes on them also and showed marked mucosal irritation and hypertrophy. the mucosal polypoid accumulations were cleared using the richards essential shaver. the turbinate was partially resected from mucosally but with good shape to it. it was not desirable to remove it in its entirety. any obvious bleeding points along the edge were controlled with the suction bovie apparatus.,the same procedure and findings were noted on the right side with 1% lidocaine with 1:100,000 epinephrine injected into the anterior portion of the right middle turbinate, polyps, and uncinate process; 10 cc total were used. the polyps were removed. the richards essential shaver was used to allow better exposure of the uncinate process. the uncinate process was removed superiorly to inferiorly with back-biting side-biting forceps.,next, a maxillary antrostomy was identified and expanded with the back-biting and side-biting forceps and showed all plate accumulations there also. the anterior and posterior ethmoid air cells were then entered primarily and dissected with richards essential shaver followed by the use of the 30-degree scope and up-biting forceps for the superior and lateral resection. the inferior turbinates showed mucosal disease, polypoid accumulations, and changes. these were removed using the richards essential shaver followed by a submucosal resection of the hypertrophied portion of the turbinate.,any obvious bleeding points were controlled with the suction bovie apparatus. a thorough irrigation was then carried out in the nasal cavity, and gelfilm packing was used to coat the linings in the middle meatal regions. the patient tolerated the procedure well and returned to the recovery room in stable condition.

preoperative diagnoses,1. cervical spinal stenosis, c3-c4 and c4-c5.,2. cervical spondylotic myelopathy.,postoperative diagnoses,1. cervical spinal stenosis, c3-c4 and c4-c5.,2. cervical spondylotic myelopathy.,operative procedures,1. radical anterior discectomy, c3-c4 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (cpt 63075).,2. radical anterior discectomy c4-c5 with removal of posterior osteophytes, foraminotomies, and decompression of the spinal canal (cpt 63076).,3. anterior cervical fusion, c3-c4 (cpt 22554),4. anterior cervical fusion, c4-c5 (cpt 22585).,5. utilization of allograft for purposes of spinal fusion (cpt 20931).,6. application of anterior cervical locking plate c3-c5 (cpt 22845).,anesthesia:, general endotracheal.,complications: , none.,estimated blood loss: ,250 cc.,operative indications: ,the patient is a 50-year-old gentleman who presented to the hospital after a fall, presenting with neck and arm pain as well as weakness. his mri confirmed significant neurologic compression in the cervical spine, combined with a clinical exam consistent with radiculopathy, myelopathy, and weakness. we discussed the diagnosis and the treatment options. due to the severity of his neurologic symptoms as well as the amount of neurologic compression seen radiographically, i recommended that he proceed with surgical intervention as opposed to standard nonsurgical treatment such as physical therapy, medications, and steroid injections. i explained the surgery itself which will be to remove pressure from the spinal cord via anterior cervical discectomy and fusion at c3-c4 and c4-c5. we reviewed the surgery itself as well as risks including infection and blood vessels or nerves, leakage of spinal fluid, weakness or paralysis, failure of the pain to improve, possible worsening of the pain, failure of the neurologic symptoms to improve, possible worsening of the neurologic symptoms, and possible need for further surgery including re-revision and/or removal. furthermore i explained that the fusion may not become solid or that the hardware could break. we discussed various techniques available for obtaining fusion and i recommended allograft and plate fixation. i explained the rationale for this as well as the options of using his own bone. furthermore, i explained that removing motion at the fusion sites will transfer stress to other disc levels possibly accelerating there degeneration and causing additional symptoms and/or necessitating additional surgery in the future.,operative technique: , after obtaining the appropriate signed and informed consent, the patient was taken to the operating room, where he underwent general endotracheal anesthesia without complications. he was then positioned supine on the operating table, and all bony prominences were padded. pulse oximetry was maintained on both feet throughout the case. the arms were carefully padded and tucked at his sides. a roll was placed between the shoulder blades. the areas of the both ears were sterilely prepped and cranial tongs were applied in routine fashion. ten pounds of traction was applied. a needle was taped to the anterior neck and an x-ray was done to determine the appropriate level for the skin incision. the entire neck was then sterilely prepped and draped in the usual fashion.,a transverse skin incision was made and carried down to the platysma muscle. this was then split in line with its fibers. blunt dissection was carried down medial to the carotid sheath and lateral to the trachea and esophagus until the anterior cervical spine was visualized. a needle was placed into a disc and an x-ray was done to determine its location. the longus colli muscles were then elevated bilaterally with the electrocautery unit. self-retaining retractors were placed deep to the longus colli muscle in an effort to avoid injury to the sympathetic chains.,radical anterior discectomies were performed at c3-c4 and c4-c5. this included complete removal of the anterior annulus, nucleus, and posterior annulus. the posterior longitudinal ligament was removed as were the posterior osteophytes. foraminotomies were then accomplished bilaterally. once all of this was accomplished, the blunt-tip probe was used to check for any residual compression. the central canal was wide open at each level as were the foramen.,a high-speed bur was used to remove the cartilaginous endplates above and below each interspace. bleeding cancellous bone was exposed. the disc spaces were measured and appropriate size allografts were placed sterilely onto the field. after further shaping of the grafts with the high-speed bur, they were carefully impacted in to position. there was good juxtaposition against the bleeding decorticated surfaces and good distraction of each interspace. all weight was then removed from the crania tongs.,the appropriate size anterior cervical locking plate was chosen and bent into gentle lordosis. two screws were then placed into each of the vertebral bodies at c3, c4, and c5. there was excellent purchase. a final x-ray was done confirming good position of the hardware and grafts. the locking screws were then applied, also with excellent purchase.,following a final copious irrigation, there was good hemostasis and no dural leaks. the carotid pulse was strong. a drain was placed deep to the level of the platysma muscle and left at the level of the hardware. the wounds were then closed in layers using 4-0 vicryl suture for the platysma muscle, 4-0 vicryl suture for the subcutaneous tissue, and 4-0 vicryl suture in a subcuticular skin closure. steri-strips were placed followed by application of a sterile dressing. the drain was hooked to bulb suction. a philadelphia collar was applied.,the cranial tongs were carefully removed. the soft tissue overlying the puncture site was massaged to free it up from the underlying bone. there was good hemostasis.,the patient was then carefully returned to the supine position on his hospital bed where he was reversed and extubated and taken to the recovery room having tolerated the procedure well.

title of operation:, endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,indication for surgery: , she is a 3-year-old girl who is known to have a head injury and ct in 2005 was normal, presented with headache. all endocrine labs were normal. surgery was recommended.,preop diagnosis: , cystic suprasellar tumor.,postop diagnosis:, cystic suprasellar tumor.,procedure detail: , the patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended. the patient was then prepped and draped in the usual sterile fashion. with the assistance of fluoro and mapping the localization, the right nostril was infiltrated. dr. x will dictate the procedure of the approach. once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling. once the operating microscope was in the field, at this point, the drilling was completed. the dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor. this was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several valsalva maneuvers were performed without any evidence of csf leak and trying to pull the tumor further down. once this was completed, there was no evidence of any bleeding. the endoscope was then used to remove any residual fragments __________ with the arachnoid. once this was completely ensured, small piece of duragel was placed and the closure will be dictated by dr. x. she was reversed, extubated, and transported to the icu in stable condition. blood loss, minimal. all sponge, needle counts were correct.

preoperative diagnosis (es):, cataract, right eye.,postoperative diagnosis (es):, cataract, right eye.,procedure:, right phacoemulsification of cataract with intraocular lens implantation.,description of the operation:, under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. a lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a superblade, and xylocaine 1% preservative free 0.25 ml was injected into the anterior chamber, which was then followed by healon to deepen the anterior chamber. using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with bss. the tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. using the phaco tip and the drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,the phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. posterior capsule was polished with a curette polisher, and healon was injected into the capsular bag. using the monarch intraocular lens inserter, the posterior chamber intraocular lens model sn60wf power +19.50 was placed into the inserter after applying some healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. intraocular lens was then rotated about half a turn with a collar button hook. healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. it was found that there was no leakage of fluid through the cornea tunnel wound. for this reason, no suture was applied. vigamox, econopred and nevanac eye drops were instilled and the eye was covered with a perforated shield. the patient tolerated the procedure well. there were no complications.

cc:, orthostatic lightheadedness.,hx:, this 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. the dizziness worsened when moving into upright positions. in addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. he had lost 40 pounds over the past year and denied any recent fever, sob, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,he had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. he has a history of sinusitis.,exam:, bp 98/80 mmhg and pulse 64 bpm (supine); bp 70/palpable mmhg and pulse 84bpm (standing). rr 12, afebrile. appeared fatigued.,cn: unremarkable.,motor and sensory exam: unremarkable.,coord: slowed but otherwise unremarkable movements.,reflexes: 2/2 and symmetric throughout all 4 extremities. plantar responses were flexor, bilaterally.,the rest of the neurologic and general physical exam was unremarkable.,lab:, na 121 meq/l, k 4.2 meq/l, cl 90 meq/l, co2 20meq/l, bun 12mg/dl, cr 1.0mg/dl, glucose 99mg/dl, esr 30mm/hr, cbc wnl with nl wbc differential, urinalysis: sg 1.016 and otherwise wnl, tsh 2.8 iu/ml, ft4 0.9ng/dl, urine osmolality 246 mosm/kg (low), urine na 35 meq/l,,course:, the patient was initially hydrated with iv normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. further laboratory studies revealed: aldosterone (serum)<2ng/dl (low), 30 minute cortrosyn stimulation test: pre 6.9ug/dl (borderline low), post 18.5ug/dl (normal stimulation rise), prolactin 15.5ng/ml (no baseline given), fsh and lh were within normal limits for males. testosterone 33ng/dl (wnl). sinus xr series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. there was also an abnormal calcification seen in the middle of the sellar region. a left maxillary sinus opacity with air-fluid level was seen. goldman visual field testing was unremarkable. brain ct and mri revealed suprasellar mass most consistent with pituitary adenoma. he was treated with fludrocortisone 0.05 mg bid and within 24hrs, despite discontinuation of iv fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. his presumed pituitary adenoma continues to be managed with fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/tia).

preoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,postoperative diagnosis:,1. cholelithiasis.,2. chronic cholecystitis.,name of operation: , laparoscopic cholecystectomy.,anesthesia:, general.,findings:, the gallbladder was thickened and showed evidence of chronic cholecystitis. there was a great deal of inflammatory reaction around the cystic duct. the cystic duct was slightly larger. there was a stone impacted in the cystic duct with the gallbladder. the gallbladder contained numerous stones which were small. with the stone impacted in the cystic duct, it was felt that probably none were within the common duct. other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,procedure:, under general anesthesia after routine prepping and draping, the abdomen was insufflated with the veress needle, and the standard four trocars were inserted uneventfully. inspection was made for any entry problems, and none were encountered.,after limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out. this was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct. in this manner, the cystic duct and cystic artery were dissected out. care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct. the cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct. the gallbladder was then dissected free from the gallbladder bed. again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction. the gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding. the gallbladder was extracted through the operating trocar site, and the trocar was reinserted. inspection was made of the gallbladder bed. one or two bleeding areas were fulgurated, and bleeding was well controlled.

chief complaint:, this 3-year-old female presents today for evaluation of chronic ear infections bilateral.,associated signs and symptoms for otitis media: , associated signs and symptoms include: cough, fever, irritability and speech and language delay. duration (ent): duration of symptom: 12 rounds of antibiotics for otitis media. quality of ear problems: quality of the pain is throbbing.,allergies: , no known medical allergies.,medications:, none currently.,pmh:, past medical history is unremarkable.,psh: , no previous surgeries.,social history:, parent admits child is in a large daycare.,family history:, parent admits a family history of alzheimer's disease associated with paternal grandmother.,ros:, unremarkable with exception of chief complaint.,physical exam:, temp: 99.6 weight: 38 lbs.,patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,the child is accompanied by her mother who communicates well in english.,head & face: inspection of head and face shows no abnormalities. examination of salivary glands shows no abnormalities. facial strength is normal.,eyes: pupil exam reveals perrla.,ent: otoscopic examination reveals otitis media bilateral.,hearing exam using tuning fork shows hearing to be diminished bilateral.,inspection of left ear reveals drainage of a small amount.,inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,frontal and maxillary sinuses all transilluminate well bilaterally.,inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,inspection of the tongue reveals normal color, good motility and midline position.,examination of oropharynx reveals no abnormalities.,examination of nasopharynx reveals adenoid hypertrophy.,neck: neck exam reveals no abnormalities.,lymphatic: no neck or supraclavicular lymphadenopathy noted.,respiratory: chest inspection reveals chest configuration non-hyperinflated and symmetric expansion. auscultation of lungs reveal clear lung fields and no rubs noted.,cardiovascular: heart auscultation reveals no murmurs, gallop, rubs or clicks.,neurological/psychiatric: testing of cranial nerves reveals no deficits. mood and affect normal and appropriate to situation.,test results:, audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,impression: , om, suppurative without spontaneous rupture. adenoid hyperplasia bilateral.,plan:, patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003. surgery will be performed at children's hospital. pre-operative consent form read and signed by parent. common risks and side effects of the procedure and anesthesia were mentioned. parent questions elicited and answered satisfactorily regarding planned procedure. ,educational material provided: , hospital preregistration, middle ear infection and myringtomy and tubes surgery.,prescriptions:, augmentin dosage: 400 mg-57 mg/5 ml powder for reconstitution sig: one po q8h dispense: 1 refills: 0 allow generic: no

chief complaint: , jaw pain.,history of present illness: ,this is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. the patient denies any facial swelling. no headache. no swelling to the throat. no sore throat. no difficulty swallowing liquids or solids. no neck pain. no lymph node swelling. the patient denies any fever or chills. denies any other problems or complaints.,review of systems:, constitutional: no fever or chills. no fatigue or weakness. heent: no headache. no neck pain. no eye pain or vision change. no rhinorrhea. no sinus congestion, pressure, or pain. no sore throat. no throat swelling. the patient does have the toothache on the left lower side that radiates towards his left ear as previously described. the patient does not have ear pain or hearing change. no pressure in the ear. cardiovascular: no chest pain. respirations: no shortness of breath. gastrointestinal: no nausea or vomiting. no abdominal pain. musculoskeletal: no back pain. skin: no rashes or lesions. neurologic: no vision or hearing change. no speech change. hematologic/lymphatic: no lymph node swelling.,past medical history: , none.,past surgical history:, none.,current medications: , none.,allergies: , no known drug allergies.,social history: , the patient smokes marijuana. the patient does not smoke cigarettes.,physical examination: , vital signs: temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal. constitutional: the patient is well nourished, well developed. the patient appears to be healthy. the patient is calm, comfortable in no acute distress, looks well. the patient is pleasant and cooperative. heent: head is atraumatic, normocephalic, and nontender. eyes are normal with clear cornea and conjunctivae bilaterally. nose, normal without rhinorrhea or audible congestion. there is no tenderness over the sinuses. ears are normal without any sign of infection. no erythema or swelling of the canals. tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it. mouth: the patient has a dental fracture at tooth #18. the patient states that the fracture is a couple of months old. the patient does not have any obvious dental caries. the gums are normal without any erythema, swelling, or evidence of infection. there is no fluctuance or suggestion of abscess. there is slight tenderness of the tooth #18. the oropharynx is normal without any sign of infection. there is no erythema, exudate, lesion, or swelling. mucous membranes are moist. floor of the mouth is normal without any tenderness or swelling. no suggestion of abscess. there is no pre or post auricular lymphadenopathy either. neck: supple. nontender. full range of motion. no meningismus. no cervical lymphadenopathy. no jvd. no carotid artery or vertebral artery bruits. cardiovascular: heart is regular rate and rhythm without murmur, rub, or gallop. respirations: clear to auscultation bilaterally. no shortness of breath. gastrointestinal: abdomen is normal and nontender. musculoskeletal: no abnormalities are noted to the back, arms, or legs. the patient has normal use of the extremities. skin: no rashes or lesions. neurologic: cranial nerves ii through xii are intact. the patient has normal speech and normal ambulation. psychiatric: the patient is alert and oriented x4. normal mood and affect. no evidence of clinical intoxification. hematologic/lymphatic: no lymphadenitis is palpated.,diagnoses:,1. acute left jaw pain.,2. #18 dental fracture, which is an ellis type ii fracture.,3. elevated blood pressure.,condition upon disposition: , stable.,disposition:, home.,plan: , we will have the patient follow up with his dentist dr. x in three to five days for reevaluation. the patient was encouraged to take motrin 400 mg q.6h. as needed for pain. the patient was given prescription for vicodin for any breakthrough or uncontrolled pain. he was given precautions for drowsiness and driving with the use of this medication. the patient was also given a prescription for pen v. the patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.

chief complaint:, questionable foreign body, right nose. belly and back pain. ,subjective: , mr. abc is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. this does not seem to be slowing him down. they have not noticed any change in his urine or bowels. they have not noted him to have any fevers or chills or any other illness. they state he is otherwise acting normally. he is eating and drinking well. he has not had any other acute complaints, although they have noted a foul odor coming from his nose. apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. his nose got better and then started to become malodorous again. mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. otherwise, he has not had any runny nose, earache, no sore throat. he has not had any cough, congestion. he has been acting normally. eating and drinking okay. no other significant complaints. he has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,past medical history: , otherwise negative.,allergies: , no allergies.,medications: , no medications other than recent amoxicillin.,social history: , parents do smoke around the house.,physical examination: , vital signs: stable. he is afebrile.,general: this is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,heent: tms, canals are normal. left naris normal. right naris, there is some foul odor as well as questionable purulent drainage. examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous. this was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual. there was some erythema. no other purulent drainage noted. there was some bloody drainage. this was suctioned and all mucous membranes were visualized and are negative.,neck: without lymphadenopathy. no other findings.,heart: regular rate and rhythm.,lungs: clear to auscultation.,abdomen: his abdomen is entirely benign, soft, nontender, nondistended. bowel sounds active. no organomegaly or mass noted.,back: without any findings. diaper area normal.,gu: no rash or infections. skin is intact.,ed course: , he also had a p-bag placed, but did not have any urine. therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine. there was a little bit of blood from catheterization but otherwise normal urine. x-ray noted some stool within the vault. child is acting normally. he is jumping up and down on the bed without any significant findings.,assessment:,1. infected foreign body, right naris.,2. mild constipation.,plan:, as far as the abdominal pain is concerned, they are to observe for any changes. return if worse, follow up with the primary care physician. the right nose, i will place the child on amoxicillin 125 per 5 ml, 1 teaspoon t.i.d. return as needed and observe for more foreign bodies. i suspect, the child had placed this cotton ball in his nose again after the first episode.

preoperative diagnoses:,1. prostatism.,2. bladder calculus.,operation:, holmium laser cystolithalopaxy.,postoperative diagnoses:,1. prostatism.,2. bladder calculus.,anesthesia: ,general.,indications:, this is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections. the cystoscopy showed a large bladder calculus, short but obstructing prostate. he comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,he is a diabetic with obesity.,laboratory data: ,includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria. he had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1. hematocrit 40.5, hemoglobin 13.8, white count 7,900.,procedure: , the patient was satisfactorily given general anesthesia. prepped and draped in the dorsal lithotomy position. a 27-french olympus rectoscope was passed via the urethra into the bladder. the bladder, prostate, and urethra were inspected. he had an obstructing prostate. he had marked catheter reaction in his bladder. he had a lot of villous changes, impossible to tell from frank tumor. he had a huge bladder calculus. it was white and round.,i used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone. there was still stone left at the end of the procedure. most of the chips that could be irrigated out of the bladder were irrigated out using ellik.,then the scope was removed and a 24-french 3-way foley catheter was passed via the urethra into the bladder.,the plan is to probably discharge the patient in the morning and then we will get a kub. we will probably bring him back for a second stage cystolithotripsy, and ultimately do a turp. we broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.

clinical history: ,probable right upper lobe lung adenocarcinoma.,specimen: , lung, right upper lobe resection.,gross description:, specimen is received fresh for frozen section, labeled with the patient's identification and "right upper lobe lung". it consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm. the specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable. sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass. this mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum. there is no necrosis or hemorrhage evident. the tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,final diagnosis:, right lung, upper lobe, lobectomy: bronchioloalveolar carcinoma, mucinous type,comment:, right upper lobe, lobectomy.,tumor type: bronchioloalveolar carcinoma, mucinous type.,histologic grade: well differentiated.,tumor size (greatest diameter): 3.6 cm.,blood/lymphatic vessel invasion: absent.,perineural invasion: absent.,bronchial margin: negative.,vascular margin: negative.,inked surgical margin: negative.,visceral pleura: not involved.,in situ carcinoma: absent.,non-neoplastic lung: emphysema.,hilar lymph nodes: number of positive lymph nodes: 0; total number of lymph nodes: 1.,p53 immunohistochemical stain is negative in the tumor.

problem: ,prescription evaluation for crohn's disease., ,history: , this is a 46-year-old male who is here for a refill of imuran. he is taking it at a dose of 100 mg per day. he is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. in fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. an x-ray was performed, which showed no signs of obstruction per his report. he thinks that the inciting factor of this incident was too many grapes eaten the day before. he has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past. the patient's normal bowel pattern is loose stools and this is unchanged recently. he has not had any rectal bleeding. he asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with iv insertion. he has not had any fever, red streaking up the arm, or enlargement of lymph nodes. the tenderness has now completely resolved. , ,he had a colonoscopy performed in august of 2003, by dr. s. an anastomotic stricture was found at the terminal ileum/cecum junction. dr. s recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation. no active crohn's disease was found during the colonoscopy. , ,earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests. at that time he was taking a lot of tylenol for migraine-type headaches. under dr. s's recommendation, he stopped the imuran for one month and reduced his dose of tylenol. since that time his liver enzymes have normalized and he has restarted the imuran with no problems. , ,he also reports heartburn that is occurring on a slightly more frequent basis than it has in the past. it used to occur once a week only, but has now increased in frequency to twice a week. he takes over-the-counter h2 blockers as needed, as well as tums. he associates the onset of his symptoms with eating spicy mexican food., ,past medical history: , reviewed and unchanged.,allergies: , no known allergies to medications.,operations: , unchanged.,illnesses: , crohn's disease, vitamin b12 deficiency.,medications:, imuran, nascobal, vicodin p.r.n., ,review of systems: , dated 08/04/04 is reviewed and noted. please see pertinent gi issues as discussed above. otherwise unremarkable., ,physical examination: , general: pleasant male in no acute distress. well nourished and well developed. skin: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length. non-tender to palpation. no erythema or red streaking. no edema. lymph: no epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,data reviewed: labs from june 8th and july 19th reviewed. liver function tests normal with ast 14 and alt 44. wbcs were slightly low at 4.8. hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04. these results were reviewed by dr. s and lab results letter sent., ,impression: ,1. crohn's disease, status post terminal ileum resection, on imuran. intermittent symptoms of bowel obstruction. last episode three weeks ago.,2. history of non-specific hepatitis while taking high doses of tylenol. now resolved. ,2. increased frequency of reflux symptoms.,3. superficial thrombophlebitis, resolving. ,4. slightly low h&h., ,plan: ,1. we discussed dr. s's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms. the patient emphatically states that he does not want to consider dilation at this time. the patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits. he states understanding of this. advised to maintain low residue diet to avoid obstructions. ,2. continue with liver panel and abc every month per dr. s's instructions.,3. continue imuran 100 mg per day.,4. continue to minimize tylenol use. the patient is wondering if he can take another type of medication for migraines that is not tylenol or antiinflammatories or aspirin. dr. s is consulted and agrees that imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. the patient will make an appointment with his primary care provider to discuss this further. ,5. reviewed the importance of prophylactic treatment of reflux-type symptoms. encouraged the patient to take over-the-counter h2 blockers on a daily basis to prevent symptoms from occurring. the patient will try this and if he remains symptomatic, then he will call our office and a prescription for zantac 150 mg per day will be provided. reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent. he does not want to undergo any type of procedure such as that at this time.,6.

without difficulty, into the upper gi tract. the anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected. all structures were visually normal in appearance. biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation. the endoscope and insufflated air were slowly removed from the upper gi tract. a repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,the patient tolerated the procedure with excellent comfort and stable vital signs. after a recovery period in the endoscopy suite, the patient is discharged to continue recovering in the family's care at home. the family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure. they will follow up with me later this week for biopsy and clo test results so that appropriate further diagnostic and therapeutic plans can be made.,

past medical history:, significant for hypertension. the patient takes hydrochlorothiazide for this. she also suffers from high cholesterol and takes crestor. she also has dry eyes and uses restasis for this. she denies liver disease, kidney disease, cirrhosis, hepatitis, diabetes mellitus, thyroid disease, bleeding disorders, prior dvt, hiv and gout. she also denies cardiac disease and prior history of cancer.,past surgical history: , significant for tubal ligation in 1993. she had a hysterectomy done in 2000 and a gallbladder resection done in 2002.,medications: , crestor 20 mg p.o. daily, hydrochlorothiazide 20 mg p.o. daily, veramist spray 27.5 mcg daily, restasis twice a day and ibuprofen two to three times a day.,allergies to medications: , bactrim which causes a rash. the patient denies latex allergy.,social history: , the patient is a life long nonsmoker. she only drinks socially one to two drinks a month. she is employed as a manager at the new york department of taxation. she is married with four children.,family history: , significant for type ii diabetes on her mother's side as well as liver and heart failure. she has one sibling that suffers from high cholesterol and high triglycerides.,review of systems: , positive for hot flashes. she also complains about snoring and occasional slight asthma. she does complain about peripheral ankle swelling and heartburn. she also gives a history of hemorrhoids and bladder infections in the past. she has weight bearing joint pain as well as low back degenerating discs. she denies obstructive sleep apnea, kidney stones, bloody bowel movements, ulcerative colitis, crohn's disease, dark tarry stools and melena.,physical examination: ,on examination temperature is 97.7, pulse 84, blood pressure 126/80, respiratory rate was 20. well nourished, well developed in no distress. eye exam, pupils equal round and reactive to light. extraocular motions intact. neuro exam deep tendon reflexes 1+ in the lower extremities. no focal neuro deficits noted. neck exam nonpalpable thyroid, midline trachea, no cervical lymphadenopathy, no carotid bruit. lung exam clear breath sounds throughout without rhonchi or wheezes however diminished. cardiac exam regular rate and rhythm without murmur or bruit. abdominal exam positive bowel sounds, soft, nontender, obese, nondistended abdomen. no palpable tenderness. no right upper quadrant tenderness. no organomegaly appreciated. no obvious hernias noted. lower extremity exam +1 edema noted. positive dorsalis pedis pulses.,assessment: , the patient is a 56-year-old female who presents to the bariatric surgery service with a body mass index of 41 with obesity related comorbidities. the patient is interested in gastric bypass surgery. the patient appears to be an excellent candidate and would benefit greatly in the management of her comorbidities.,plan: , in preparation for surgery will obtain the usual baseline laboratory values including baseline vitamin levels. will proceed with our usual work up with an upper gi series as well as consultations with the dietician and the psychologist preoperatively. i have recommended six weeks of medifast for the patient to obtain a 10% preoperative weight loss.

preoperative diagnosis: , umbilical hernia.,postoperative diagnosis: , umbilical hernia.,procedure performed: , repair of umbilical hernia.,anesthesia: , general.,complications: , none.,estimated blood loss: , minimal.,procedure in detail: ,the patient was prepped and draped in the sterile fashion. an infraumbilical incision was formed and taken down to the fascia. the umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% marcaine. the skin was reattached to the fascia with 2-0 vicryls. the skin was approximated with 2-0 vicryl subcutaneous and then 4-0 monocryl subcuticular stitches, dressed with steri-strips and 4 x 4's. patient was extubated and taken to the recovery area in stable condition.

preoperative diagnosis:, recurring bladder infections with frequency and urge incontinence, not helped with detrol la.,postoperative diagnosis: , normal cystoscopy with atrophic vaginitis.,procedure performed: , flexible cystoscopy.,findings:, atrophic vaginitis.,procedure: ,the patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position. the patient then had flexible scope placed through the urethral meatus and into the bladder. bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body. significant atrophic vaginitis is noted.,impression: , atrophic vaginitis with overactive bladder with urge incontinence.,plan: , the patient will try vesicare 5 mg with estrace and follow up in approximately 4 weeks.

preoperative diagnoses:,1. enlarged fibroid uterus.,2. abnormal uterine bleeding.,postoperative diagnoses:,1. enlarged fibroid uterus.,2. abnormal uterine bleeding.,procedure performed: , total abdominal hysterectomy with a uterosacral vault suspension.,anesthesia: , general with endotracheal tube as well as spinal with astramorph.,estimated blood loss: , 150 cc.,urine output: ,250 cc of clear urine at the end of the procedure.,fluids:, 2000 cc of crystalloids.,complications: , none.,tubes: , none.,drains: ,foley to gravity.,pathology: , uterus, cervix, and multiple fibroids were sent to pathology for review.,findings: ,on exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally. the appendix was normal appearing. the bowel and omentum were normal appearing. there was no evidence of endometriosis. peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,procedure:, after informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where first a spinal anesthesia with astramorph was obtained without any difficulty. she then underwent a general anesthesia with endotracheal tube also without any difficulty. she was then examined under anesthesia with noted findings as above. the patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion.. a vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis. this was made with a first knife and then carried down to the underlying layer of the fascia with the second knife. fascia was excised in the midline and extended superiorly and inferiorly with the mayo scissors. the rectus muscle was then separated in the midline. the peritoneum identified and entered bluntly. the peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder. the uterus was markedly evident upon entering the peritoneal cavity. the uterus was then exteriorized and noted to have the findings as above. at this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the bovie and then using a blunt and the sharp dissection and grasping with lahey clamps. once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 vicryl sutures in a figure-of-eight fashion. the round ligaments were identified bilaterally and clamped with the hemostats and transacted with the metzenbaum scissors. the round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic. the uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments. the uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight ochsner clamps and transacted and suture tied with a heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic. at this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with allis clamps and the bladder flap was then created sharply with russian pickups and the metzenbaum scissors. then the bladder was bluntly dissected off the underlying cervix with a moist ray-tec sponge down to the level of the cervix.,at this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized. using #2-0 pds suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial. these sutures were then tagged and saved for later. the uterine vessels were then identified bilaterally and skeletonized, then clamped with straight ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 vicryl and noted to be hemostatic. in a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved ochsner and transacted and suture ligated and noted to be hemostatic. at this point, the lahey clamp was placed on the cervix and the cervix was tented up. the pubocervical vesical fascia was transacted with long knife. then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight ochsner clamp. the uterus and cervix were then amputated using the jorgenson scissors and the cuff was outlined with ochsner clamps. the cuff was then copiously painted with betadine soaked sponge. the betadine-soaked sponge was placed in the patient's vagina. then the cuff was then closed with a #0 vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff. this was accomplished with one #0 vicryl running stitch and then an allis clamp was placed in the midsection portion of the cuff and tented up and a #0 vicryl figure-of-eight was placed in the midsection portion of the cuff. at this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side. the needle was cut off and these were then tagged with the hemostats. the cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together. the suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff. the abdomen was copiously irrigated with warm normal saline. all areas were noted to be hemostatic. then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments. the abdomen was then once again copiously irrigated with warm normal saline. all areas were noted to be hemostatic. the sigmoid colon was replaced back into the hollow of the sacrum. then the omentum was pulled over the bowel. after the myomectomy was performed, the gyn balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges. the gyn balfour was then removed. packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 vicryl.,skin was closed with staples. the patient tolerated the procedure well. the sponge, lap, and needle counts were correct x2. the sponge from the patient's vagina was removed and the vagina was noted to be hemostatic. the patient would be followed throughout her hospital stay.

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.

history: , the patient is a 56-year-old right-handed female with longstanding intermittent right low back pain, who was involved in a motor vehicle accident in september of 2005. at that time, she did not notice any specific injury. five days later, she started getting abnormal right low back pain. at this time, it radiates into the buttocks down the posterior aspect of her thigh and into the right lateral aspect of her calf. symptoms are worse when sitting for any length of time, such as driving a motor vehicle. mild symptoms when walking for long periods of time. relieved by standing and lying down. she denies any left leg symptoms or right leg weakness. no change in bowel or bladder function. symptoms have slowly progressed. she has had medrol dosepak and analgesics, which have not been very effective. she underwent a spinal epidural injection, which was effective for the first few hours, but she had recurrence of the pain by the next day. this was done four and a half weeks ago.,on examination, lower extremities strength is full and symmetric. straight leg raising is normal.,objective:, sensory examination is normal to all modalities. full range of movement of lumbosacral spine. mild tenderness over lumbosacral paraspinal muscles and sacroiliac joint. deep tendon reflexes are 2+ and symmetric at the knees, 2 at the left ankle and 1+ at the right ankle.,nerve conduction studies:, motor and sensory distal latencies, evoked response, amplitudes, conduction velocities, and f-waves are normal in the lower extremities. right tibial h-reflex is slightly prolonged when compared to the left tibial h-reflex.,needle emg:, needle emg was performed in both lower extremities and lumbosacral paraspinal muscles using the disposable concentric needle. it revealed increased insertional activity in the right mid and lower lumbosacral paraspinal muscles as well as right peroneus longus muscle. there were signs of chronic denervation in right tibialis anterior, peroneus longus, gastrocnemius medialis, and left gastrocnemius medialis muscles.,impression: , this electrical study is abnormal. it reveals the following:,1. a mild right l5 versus s1 radiculopathy.,2. left s1 nerve root irritation. there is no evidence of active radiculopathy.,3. there is no evidence of plexopathy, myopathy or peripheral neuropathy.,mri of the lumbosacral spine was personally reviewed and reveals bilateral l5-s1 neuroforaminal stenosis, slightly worse on the right. results were discussed with the patient and her daughter. i would recommend further course of spinal epidural injections with dr. xyz. if she has no response, then surgery will need to be considered. she agrees with this approach and will followup with you in the near future.

s:, the patient is here today with his mom for several complaints. number one, he has been having issues with his right shoulder. approximately 10 days ago he fell, slipping on ice, did not hit his head but fell straight on his shoulder. he has been having issues ever since. he is having difficulties raising his arm over his head. he does have some intermittent numbness in his fingers at night. he is not taking any anti-inflammatories or pain relievers. he is also complaining of a sore throat. he did have some exposure to strep and he has a long history of strep throat. denies any fevers, rashes, nausea, vomiting, diarrhea, and constipation. he is also being seen for adhd by dr. b. adderall and zoloft. he takes these once a day. he does notice when he does not take his medication. he is doing well in school. he is socializing well. he is maintaining his weight and tolerating the medications. however, he is having issues with anger control. he realizes when he has anger outbursts that it is a problem. his mom is concerned. he actually was willing to go to counseling and was wondering if there was anything available for him at this time.,past medical/surgical/social history:, reviewed and unchanged.,o:, vss. in general, patient is a&ox3. nad. heart: rrr. lungs: cta. heent: unremarkable. he does have 2+ tonsils, no erythema or exudate noted except for some postnasal drip. musculoskeletal: limited in range of motion, active on the right. he stops at about 95 degrees. no muscle weakness. neurovascularly intact. negative biceps tenderness. psych: no suicidal, homicidal ideations. answering questions appropriately. no hallucinations.

history of present illness: , this is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for q-fever endocarditis. he is also taking digoxin, aspirin, warfarin, and furosemide. mother reports that he does have problems with 2-3 loose stools per day since september, but tolerates this relatively well. this has not increased in frequency recently.,mark recently underwent surgery at children's hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of gore-tex membrane pericardial substitute. he tolerated this procedure well. he has been doing well at home since that time.,physical examination:,vital signs: temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,general appearance: well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,heent: remarkable for the badly degenerated left lower molar. funduscopic exam is unremarkable.,neck: supple without adenopathy.,chest: clear including the sternal wound.,cardiovascular: a 3/6 systolic murmur heard best over the upper left sternal border.,abdomen: soft. he does have an enlarged spleen, however, given his obesity, i cannot accurately measure its size.,gu: deferred.,extremities: examination of extremities reveals no embolic phenomenon.,skin: free of lesions.,neurologic: grossly within normal limits.,laboratory data: , doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5. hydroxychloroquine level obtained at that time was undetectable. of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/ml. q-fever serology obtained on 10/05/2007 was positive for phase i antibodies in 1/2/6 and phase ii antibodies at 1/128, which is an improvement over previous elevated titers. studies on the pulmonary valve tissue removed at surgery are pending.,impression: , q-fever endocarditis.,plan: ,1. continue doxycycline and hydroxychloroquine. i carefully questioned mother about compliance and concomitant use of dairy products while taking these medications. she assures me that he is compliant with his medications. we will however repeat his hydroxychloroquine and doxycycline levels.,2. repeat q-fever serology.,3. comprehensive metabolic panel and cbc.,4. return to clinic in 4 weeks.,5. clotting times are being followed by dr. x.

reason for referral: , elevated bnp.,history of present illness:, the patient is a 95-year-old caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's bnp level was high, for which cardiology consult was requested. the patient denies any chest pain or shortness of breath. chest x-ray and cat scan shows possible pneumonia. the patient denies any prior history of coronary artery disease but has a history of hypertension.,allergies: , no known drug allergies.,medications:, at this time, he is on:,1. atrovent and albuterol nebulizers.,2. azithromycin.,3. potassium chloride 10 meq p.o. daily.,4. furosemide 20 mg iv daily.,5. enoxaparin 40 mg daily.,6. lisinopril 10 mg p.o. daily.,7. ceftriaxone.,past medical history: , history of hypertension.,past surgical history:, history of abdominal surgery.,social history: , he does not smoke. drinks occasionally.,family history: ,noncontributory.,review of systems: , denies chest pain, pnd, or orthopnea. he has cough. no fever. no abdominal pain. no syncope, near-syncope, or palpitation. all other systems were reviewed.,physical examination:,general: the patient is comfortable, not in distress.,vital signs: his blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,heent: atraumatic, normocephalic. eyes perrla.,neck: supple. no jvd. no carotid bruit.,chest: clear.,heart: s1 and s2, regular. no s3. no s4. no murmur.,abdomen: soft, nontender. positive bowel sounds.,extremities: no cyanosis, clubbing, or edema. pulse 2+.,cns: alert, awake, and oriented x3.,diagnostic data:, ekg shows sinus tachycardia, nonspecific st-t changes, nonspecific intraventricular conduction delay. ct chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe. loculated pleural effusion in the left upper lobe. no pe. chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,laboratory data: , sodium 139, potassium 4.1, bun 26, creatinine 0.9, bnp 331, troponin less than 0.05. white cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,assessment:,1. pneumonia.,2. diastolic heart failure, not contributing to his present problem.,3. hypertension, controlled.,4. history of falls.,plan: , we will continue iv low-dose diuretics, continue lisinopril, continue iv antibiotics. no further cardiac workup at this time.

discharge diagnoses:,1. end-stage renal disease, on hemodialysis.,2. history of t9 vertebral fracture.,3. diskitis.,4. thrombocytopenia.,5. congestive heart failure with ejection fraction of approximately 30%.,6. diabetes, type 2.,7. protein malnourishment.,8. history of anemia.,history and hospital course: , the patient is a 77-year-old white male who presented to hospital of bossier on april 14, 2008. the patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization. he also needed to continue with dialysis and he needed to improve his rehabilitation. the patient tolerated his medication well and he was going through rehab fairly well without any significant troubles. he did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management. the patient had remained afebrile. he did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at promise. on the day of discharge, on may 9, 2008, the patient was in good spirits, was very clear and lucid. he denied any complaints of pain. he did have some trouble with sleep at night at times, but i think this was mainly tied into the fact that he sleeps a lot during the day. the patient has increased his appetite some and has been eating some. his vital signs remain stable. his blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3. ppd was negative. an sms form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at promise.,the patient and his family understood our plan and agreed with it. he thanked us for the care that he received at promise and thought that they did a fantastic job taking care of him. he did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,

history: , the patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg. she was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee. this has required large amounts of opioid analgesics to control. she has been basically bedridden because of this. she was brought into hospital for further investigations.,physical examination: , on examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement. difficult to assess individual muscles, but strength is largely intact. sensory examination is symmetric. deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression. she has slightly decreased right versus left ankle reflexes. the babinski's are positive. on nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and f-waves are normal in lower extremities.,needle emg: , needle emg was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle. it reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles. there is evidence of denervation in right gastrocnemius medialis muscle.,impression: , this electrical study is abnormal. it reveals the following:,1. inactive right s1 (l5) radiculopathy.,2. there is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,results were discussed with the patient and she is scheduled for imaging studies in the next day.

preoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,postoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,procedures,1. anterior cervical discectomy, c3-c4, c2-c3.,2. anterior cervical fusion, c2-c3, c3-c4.,3. removal of old instrumentation, c4-c5.,4. fusion c3-c4 and c2-c3 with instrumentation using abc plates.,procedure in detail: , the patient was placed in the supine position. the neck was prepped and draped in the usual fashion for anterior cervical discectomy. a high incision was made to allow access to c2-c3. skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. this exposed the vertebral bodies of c2-c3 and c4-c5 which was bridged by a plate. we placed in self-retaining retractors. with the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of c2, c3, c4, and c5. after having done this, we used the all-purpose instrumentation to remove the instrumentation at c4-c5, we could see that fusion at c4-c5 was solid.,we next proceeded with the discectomy at c2-c3 and c3-c4 with disc removal. in a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. it was obvious that the c3-c4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. with the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at c2-c3 and c3-c4. we then placed the abc 55-mm plate from c2 down to c4. these were secured with 16-mm titanium screws after excellent purchase. we took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. the next step was to irrigate the wound copiously with saline and bacitracin solution and s jackson-pratt drain was placed in the prevertebral space and brought out through a separate incision. the wound was closed with 2-0 vicryl for subcutaneous tissues and steri-strips used to close the skin. blood loss was about 50 ml. no complication of the surgery. needle count, sponge count, cottonoid count was correct.,the operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. at the time of surgery, he had total collapse of the c2, c3, and c4 disc with osteophyte formation. at both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. he does have degenerative changes at c5-c6, c6-c7, c7-t1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.

title of operation:, left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,indication for surgery: , the patient is a patient well known to my service. she came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull. i took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life. i spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor gcs of 3 in some brainstem reflexes. i discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1. we went to the operating room at that time and we did a very large right-sided hemicraniectomy. the patient was put in the intensive care unit. we had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago. over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk. we obtained a ct scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift. at this point, once again i discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________ this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,procedure in detail: , the patient was taken to the operating room. she was already intubated and under general anesthesia. the head was put in a 3-pin mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin mayfield headholder. the patient tolerated this well. we sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a t-shaped incision with t vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin. we connected this. prior to this, we brought in all surgical instrumentation under sterile and standard conditions. we opened the skin as in opening a book and then we also did a myocutaneous flap. we brought in the muscle with it. we had a very good exposure of the skull. we identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly. we had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side. at this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly. all this was irrigated thoroughly. once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely. we had absolutely good hemostasis. we put a piece of gelfoam over the brain. we had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position. i went ahead and irrigated everything thoroughly putting a piece of duragen as well as a piece of gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place. this running nylon we put in place in order not to put any absorbables, although i put a few 0 popoffs just to approximate the skin nicely. once we had done this, irrigated thoroughly once again the skin. we cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit. the ebl was about 200 cubic centimeters. her hematocrit went down to about 21 and i ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct. no complications. the patient went back to the intensive care unit.

preoperative diagnosis: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,postoperative diagnoses: , cervical myelopathy, c3-4, secondary to stenosis from herniated nucleus pulposus, c3-4.,operative procedures,1. anterior cervical discectomy with decompression, c3-4.,2. arthrodesis with anterior interbody fusion, c3-4.,3. spinal instrumentation using pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4. implant using peek 7 mm.,5. allograft using vitoss.,drains: , round french 10 jp drain.,fluids: , 1800 ml of crystalloids.,urine output: ,1000 ml.,specimens: , none.,complications: ,none.,anesthesia: , general endotracheal anesthesia.,estimated blood loss: ,less than 100 ml.,condition: ,to postanesthesia care unit extubated with stable vital signs.,indications for the operation: ,this is a case of a very pleasant 32-year-old caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop. since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening. about two days ago, he started noticing weakness on the left arm. the patient also noted shuffling gait. the patient presented to a family physician and was referred to dr. x for further evaluation. dr. x could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an mri of the brain was essentially unremarkable as well as mri of the thoracic spine. mri of the cervical spine, however, revealed an acute disk herniation at c3-c4 with evidence of stenosis and cord changes. based on these findings, i recommended decompression. the patient was started on decadron at 10 mg iv q.6h. operation, expected outcome, risks, and benefits were discussed with him. risks to include but not exclusive of bleeding and infection. bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma. the hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function. should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma. there is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient. there is also the possibility of infection, which can be superficial and treated with iv and p.o. antibiotics. however, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation. this may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed. there is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele. this too can compromise airway and may require return to the operating room for repair of the dural tear. there is also potential risk of injury to the esophagus, the trachea, as well as the carotid. the patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation. the patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,description of procedure: ,the patient was brought to the operating room, awake, alert and not in any form of distress. after smooth induction and intubation, a foley catheter was inserted. no monitoring leads were placed. the patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders. localizing x-ray verified the marker to be right at the c3-4 interspace. proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length. the area was then prepped with duraprep.,after sterile drapes were laid out, an incision was made using a scalpel blade #10. wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion. the anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath. the prevertebral fascia was identified. localizing x-ray verified another marker to be at the c3-4 interspace. proceeded to strip the longus colli muscles off the vertebral body of c3 and c4 and a self-retaining retractor was then laid out. there was some degree of anterior osteophyte and this was carefully drilled down with a midas 5-mm bur. the disk was then cut through the annulus and removal of the disk was done with the use of the midas 5-mm bur and later a 3-mm bur. the inferior endplate of c3 and the superior endplate of c4 were likewise drilled out together with posterior inferior osteophyte at the c3 and the posterior superior osteophyte at c4. there was note of a central disk herniation centrally, but more marked displacement of the cord on the left side. by careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed. hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of gelfoam on the patient's left because of profuse venous bleeder. with this completed, the valsalva maneuver showed no evidence of any csf leakage. a 7-mm implant with its interior packed with vitoss was then tapped into place. an 18-mm plate was then screwed down with four 14 x 4.0 mm screws. the area was irrigated with saline, with bacitracin solution. postoperative x-ray showed excellent placement of the graft and spinal instrumentation. a round french 10 jp drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly. the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures for the platysma, vicryl 4-0 subcuticular stitch for the dermis and dermabond. the catheter was anchored to the skin with a nylon 3-0 stitch. dressing was placed only on the exit site of the drain. c-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.

history of present illness: ,the patient is a 78-year-old woman here because of recently discovered microscopic hematuria. history of present illness occurs in the setting of a recent check up, which demonstrated red cells and red cell casts on a routine evaluation. the patient has no new joint pains; however, she does have a history of chronic degenerative joint disease. she does not use nonsteroidal agents. she has had no gross hematuria and she has had no hemoptysis.,review of systems: , no chest pain or shortness of breath, no problem with revision. the patient has had decreased hearing for many years. she has no abdominal pain or nausea or vomiting. she has no anemia. she has noticed no swelling. she has no history of seizures.,past medical history: , significant for hypertension and hyperlipidemia. there is no history of heart attack or stroke. she has had bilateral simple mastectomies done 35 years ago. she has also had one-third of her lung removed for carcinoma (probably an adeno ca related to a pneumonia.) she also had hysterectomy in the past.,social history: , she is a widow. she does not smoke.,medications:,1. dyazide one a day.,2. pravachol 80 mg a day in the evening.,3. vitamin e once a day.,4. one baby aspirin per day.,family history:, unremarkable.,physical examination:, she looks younger than her stated age of 78 years. she was hard of hearing, but could read my lips. respirations were 16. she was afebrile. pulse was about 90 and regular. her gait was normal. blood pressure is 140/70 in her left arm seated. heent: she had arcus cornealis. the pupils were equal. the sclerae were not icteric. the conjunctivae were pink. neck: the thyroid is not palpated. no nodes were palpated in the neck. chest: clear to auscultation. she had no sacral edema. cardiac: regular, but she was tachycardic at the rate of about 90. she had no diastolic murmur. abdomen: soft, and nontender. i did not palpate the liver. extremities: she had no appreciable edema. she had no digital clubbing. she had no cyanosis. she had changes of the degenerative joint disease in her fingers. she had good pedal pulses. she had no twitching or myoclonic jerks.,laboratory data: , the urine, i saw 1-2 red cells per high power fields. she had no protein. she did have many squamous cells. the patient has creatinine of 1 mg percent and no proteinuria. it seems unlikely that she has glomerular disease; however, we cannot explain the red cells in the urine.,plan: , to obtain a routine sonogram. i would also repeat a routine urinalysis to check for blood again. i have ordered a c3 and c4 and if the repeat urine shows red cells, i will recommend a cystoscopy with a retrograde pyelogram.

preoperative diagnoses: ,1. right lower extremity radiculopathy with history of post laminectomy pain.,2. epidural fibrosis with nerve root entrapment.,postoperative diagnoses: ,1. right lower extremity radiculopathy with history of post laminectomy pain.,2. epidural fibrosis with nerve root entrapment.,operation performed: , right l4, attempted l5, and s1 transforaminal epidurogram for neural mapping.,anesthesia:, local/iv sedation.,complications: , none.,summary: , the patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. the patient was given sedation and monitored. local anesthetic was used to insufflate the skin and paraspinal tissues and the l5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the l5 root. the left side was quite open; however, that was not the side of her problem. at this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of l5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the l4 nerve root. a second needle was taken and placed at the s1 nerve foramen using ap and lateral fluoroscopic views to confirm location. after negative aspiration, 2 cc of omnipaque 240 dye was injected through each needle.,there was a defect flowing in the medial epidural space at both sides. there were no complications.

principal diagnosis:, knee osteoarthrosis.,principal procedure: , total knee arthroplasty.,history and physical:, a 66-year-old female with knee osteoarthrosis. failed conservative management. risks and benefits of different treatment options were explained. informed consent was obtained.,past surgical history: , right knee surgery, cosmetic surgery, and carotid sinus surgery.,medications: , mirapex, ibuprofen, and ambien.,allergies: , questionable penicillin allergies.,physical examination: , general: female who appears younger than her stated age. examination of her gait reveals she walks without assistive devices.,heent: normocephalic and atraumatic.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm.,abdomen: soft.,extremities: grossly neurovascularly intact.,hospital course: , the patient was taken to the operating room (or) on 03/15/2007. she underwent right total knee arthroplasty. she tolerated this well. she was taken to the recovery room. after uneventful recovery room course, she was brought to regular surgical floor. mechanical and chemical deep venous thrombosis (dvt) prophylaxis were initiated. routine postoperative antibiotics were administered. hemovac drain was discontinued on postoperative day #2. physical therapy was initiated. continuous passive motion (cpm) was also initiated. she was able to spontaneously void. she transferred to oral pain medication. incision remained clean, dry, and intact during the hospital course. no pain with calf squeeze. she was felt to be ready for discharge home on 03/19/2007.,disposition: ,discharged to home.,follow up:, follow up with dr. x in one week. prescriptions were written for percocet and coumadin.,instructions: , home physical therapy and pt and inr to be drawn at home for adjustment of coumadin dosing.,

history of present illness:, the patient is a 43-year-old male who was recently discharged from our care on the 1/13/06 when he presented for shortness of breath. he has a past history of known hyperthyroidism since 1992 and a more recent history of atrial fibrillation and congestive cardiac failure with an ejection fraction of 20%-25%. the main cause for his shortness of breath was believed to be due to atrial fibrillation secondary to hyperthyroidism in a setting with congestive cardiac failure. during his hospital stay, he was commenced on metoprolol for rate control, and given that he had atrial fibrillation, he was also started on warfarin, which his inr has been followed up by the homeless clinic. for his congestive cardiac failure, he was restarted on digoxin and lisinopril. for his hyperthyroidism, we restarted him on ptu and the endocrinologists were happy to review him when he was euthymic to discuss further radioiodine or radiotherapy. he was restarted on ptu and discharged from the hospital on this medication. while in the hospital, it was also noted that he abused cigarettes and cocaine, and we advised strongly against this given the condition of his heart. it was also noted that he had elevated liver function tests, which an ultrasound was normal, but his hepatitis panel was pending. since his discharge, his hepatitis panel has come back normal for hepatitis a, b, and c. since discharge, the patient has complained of shortness of breath, mainly at night when lying flat, but otherwise he states he has been well and compliant with his medication.,medications:, digoxin 250 mcg daily, lisinopril 5 mg daily, metoprolol 50 mg twice daily, ptu (propylthiouracil) 300 mg orally four times a day, warfarin variable dose based on inr.,physical examination:,vital signs: he was afebrile today. blood pressure 114/98. pulse 92 but irregular. respiratory rate 25.,heent: obvious exophthalmus, but no obvious lid lag today.,neck: there was no thyroid mass palpable.,chest: clear except for occasional bibasilar crackles.,cardiovascular: heart sounds were dual, but irregular, with no additional sounds.,abdomen: soft, nontender, nondistended.,extremities: mild +1 peripheral edema in both legs.,plan:, the patient has also been attending the homeless clinic since discharge from the hospital, where he has been receiving quality care and they have been looking after every aspect of his health, including his hyperthyroidism. it is our recommendation that a tsh and t4 be continually checked until the patient is euthymic, at which time he should attend endocrine review with dr. huffman for further treatment of his hyperthyroidism. regarding his atrial fibrillation, he is moderately rate controlled with metoprolol 50 mg b.i.d. his rate in clinic today was 92. he could benefit from increasing his metoprolol dose, however, in the hospital it was noted that he was bradycardic in the morning with a pulse rate down to the 50s, and we were concerned with making this patient bradycardic in the setting of congestive cardiac failure. regarding his congestive cardiac failure, he currently appears stable, with some variation in his weight. he states he has been taking his wife's lasix tablets for diuretic benefit when he feels weight gain coming on and increased edema. we should consider adding him on a low-dose furosemide tablet to be taken either daily or when his weight is above his target range. a digoxin level has not been repeated since discharge, and we feel that this should be followed up. we have also increased his lisinopril to 5 mg daily, but the patient did not receive his script upon departing our clinic. regarding his elevated liver function tests, we feel that these are very likely secondary to hepatic congestion secondary to congestive cardiac failure with a normal ultrasound and normal hepatitis panel, but yet the liver function tests should be followed up.

chief complaint:, here with a concern of possibly issues of short-term memory loss. she is under exceeding amount of stress over the last 5 to 10 years. she has been a widow over the last 11 years. her husband died in an mva from a drunk driver accident. she had previously worked at the bank in conway springs in norwich and had several other jobs related to accounting or management services. she does have an mba in business. currently, she works at t-mobile customer service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. she feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. she describes the job is very demanding and high stress. she denies any history of weakness, lethargy, or dizziness. no history of stroke.,current medications:, vioxx 25 mg daily, hctz 25 mg one-half tablet daily, zoloft 100 mg daily, zyrtec 10 mg daily.,allergies to medications: , naprosyn.,social history, family history, past medical history and surgical history: , she has had hypertension very well controlled and history of elevated triglycerides. she has otherwise been generally healthy. nonsmoker. please see notes dated 06/28/2004.,review of systems:, review of systems is otherwise negative.,physical examination:,vital signs: age: 60. weight: 192 pounds. blood pressure: 134/80. temperature: 97.8 degrees.,general: a very pleasant 60-year-old white female in no acute distress. alert, ambulatory and nonlethargic.,heent: perrla. eoms are intact. tms are clear bilaterally. throat is clear.,neck: supple. no cervical adenopathy.,lungs: clear without wheezes or rales.,heart: regular rate and rhythm.,abdomen: soft nontender to palpation.,extremities: moving all extremities well.,impression:,1. short-term memory loss, probable situational.,2. anxiety stress issues.,plan:, thirty-minute face-to-face appointment in counseling with the patient. at length discussion on her numerous stress issues which can certainly cause a loss of concentration and inability to learn. the current job she is at does sound extremely stressful and demanding. i think her stress reactions to these as far as feeling frustrated are within normal limits. we did complete a mini mental state exam including clock drawing, sentence writing, signature, etc. she does score a maximum score of 30/30 and all other tasks were completed without difficulty or any hesitation. i did spend quite a bit of time reassuring her as well. she is currently on zoloft 100 mg which i think is an appropriate dose. we will have her continue on that. she did verbalize understanding and that she actually felt better after our discussion concerning these issues. at some point in time; however, i would possibly recommend job change if this one would persist as far as the stress levels. she is going to think about that.

subjective:, this is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. patient reports that she had gestational diabetes with her first pregnancy. she did use insulin at that time as well. she does not fully understand what ketones are. she walks her daughter to school and back home each day which takes 20 minutes each way. she is not a big milk drinker, but she does try to drink some.,objective:, weight is 238.3 pounds. weight from last week’s visit was 238.9 pounds. prepregnancy weight is reported at 235 pounds. height is 62-3/4 inches. prepregnancy bmi is approximately 42-1/2. insulin schedule is novolog 70/30, 20 units in the morning and 13 units at supper time. blood sugar records for the last week reveal the following: fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116. overall average is 140. a diet history was obtained. expected date of confinement is may 1, 2005. instructed the patient on dietary guidelines for gestational diabetes. a 2300 meal plan was provided and reviewed. the lily guide for meal planning was provided and reviewed.,assessment:, patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day. her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day. her diet history reveals that she is eating three meals a day and three snacks. the snacks were just added last week following presence of ketones in her urine. we identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most. we identified 15 gram equivalents of carbohydrate and established a carbohydrate budget. we also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy. we discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars. while a sample meal plan was provided reflecting the patient’s carbohydrate budget i emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day. patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis. at the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,plan:, recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate. breakfast: three carbohydrate servings. morning snack: one carbohydrate serving. lunch: four carbohydrate servings. afternoon snack: one carbohydrate serving. supper: four carbohydrate servings. bedtime snack: one carbohydrate serving. encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack. encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy. recommend patient include a fruit or a vegetable with most of her meals. also recommend including solid protein with each meal as well as with the bedtime snack. charlie athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment: morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units. patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial. provided my name and number should there be additional dietary questions.

chief complaint:, well-child check and school physical.,history of present illness:, this is a 9-year-old african-american male here with his mother for a well-child check. mother has no concerns at the time of the visit. she states he had a pretty good school year. he still has some fine motor issues, especially writing, but he is receiving help with that and math. he continues to eat well. he could do better with milk intake, but mother states he does eat cheese and yogurt. he brushes his teeth daily. he has regular dental visits every six months. bowel movements are without problems. he is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,developmental assessment:, social: he has a sense of humor. he knows his rules. he does home chores. fine motor: he is as mentioned before. he can draw a person with six parts. language: he can tell time. he knows the days of the week. he reads for pleasure. gross motor: he plays active games. he can ride a bicycle.,review of systems:, he has had no fever and no vision problems. he had an eye exam recently with dr. crum. he has had some headaches which precipitated his vision exam. no earache or sore throat. no cough, shortness of breath or wheezing. no stomachache, vomiting or diarrhea. no dysuria, urgency or frequency. no excessive bleeding or bruising.,medications:, no daily medications.,allergies:, cefzil.,immunizations:, his immunizations are up to date.,physical examination:,general: he is alert and in no distress, afebrile.,heent: normocephalic, atraumatic. pupils equal, round and react to light. tms are clear bilaterally. nares: patent. oropharynx is clear.,neck: supple.,lungs: clear to auscultation.,heart: regular. no murmur.,abdomen: soft. positive bowel sounds. no masses. no hepatosplenomegaly.,gu: tanner iii.,extremities: symmetrical. femoral pulses 2+ bilaterally. full range of motion of all extremities.,back: no scoliosis.,neurological: grossly intact.,skin: normal turgor. no rashes.,hearing: grossly normal.,assessment:, well child.,plan:, anticipatory guidance for age. he is to return to the office in one year.

procedure:, flexible bronchoscopy.,preoperative diagnosis (es):, chronic wheezing.,indications for procedure:, evaluate the airway.,description of procedure: ,this was done in the pediatric endoscopy suite with the aid of anesthesia. the patient was sedated with sevoflurane and propofol. one ml of 1% lidocaine was used for airway anesthesia. the 2.8-mm flexible pediatric bronchoscope was passed through the left naris. the upper airway was visualized. the epiglottis, arytenoids, and vocal cords were all normal. the scope was passed below the cords. the subglottic space was normal. the patient had normal tracheal rings and a normal membranous portion of the trachea. there was noted to be slight deviation of the trachea to the right. at the carina, the right and left mainstem were evaluated. the right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. the scope was wedged in the right middle lobe, 10 ml of saline was infused, 10 was returned. this was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. the left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. there was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. the left upper lobe and left lower lobe were normal. the scope was withdrawn. the patient tolerated the procedure well.,endoscopic diagnosis:, left mainstem bronchomalacia.

reason for catheterization:, st-elevation myocardial infarction.,procedures undertaken,1. left coronary system cineangiography.,2. right coronary system cineangiography.,3. left ventriculogram.,4. pci to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.,procedure: , after all risks and benefits were explained to the patient, informed consent was obtained. the patient was brought to the cardiac cath suite. right groin was prepped in usual sterile fashion. right common femoral artery was cannulated with the modified seldinger technique. a 6-french sheath was introduced. next, judkins right catheter was used to engage the right coronary artery and cineangiography was recorded in multiple views. next, an ebu 3.5 guide was used to engage the left coronary system. cineangiography was recorded in several views and it was noted to have a 99% proximal left circumflex stenosis. angiomax bolus and drip were started after checking an act, which was 180, and an universal wire was advanced through the left circumflex beyond the lesion. next, a 3.0 x 12 mm balloon was used to pre-dilate the lesion. next a 3.5 x 12 mm vision bare-metal stent was advanced to the area of stenosis and deployed at 12 atmospheres. there was noted to be a plaque shift proximally at the edge of the stent. therefore, a 3.5 x 8 mm vision bare-metal stent was advanced to cover the proximal margin of the first stent and deployed at 12 atmospheres. next, a 3.75 x 13 mm noncompliant balloon was advanced into the margin of the stent and two inflations at 20 atmospheres were done for 20 seconds. final images showed excellent results with initial 99% stenosis reduced to 0%. the patient continues to have residual stenosis in the mid to distal in the om branch. at this point, wire was removed. final images confirmed initial stent results, no evidence of dissection, perforation, or complications.,next, an angled pigtail catheter was advanced into the left ventricular cavity. lv pressure was measured. lv gram was done in both the lao and rao projections and a pullback gradient across the aortic valve was done and recorded. finally, all guides were removed. right femoral artery access site was imaged and angio-seal deployed to attain excellent hemostasis. the patient tolerated the procedure very well without complications.,diagnostic findings,1. left main: left main is a large-caliber vessel bifurcating in lad and left circumflex with no significant disease.,2. the lad: lad is a large-caliber vessel, wraps around the apex, gives off multiple septal perforators, three small-to-medium caliber diagonal branches without any significant disease.,3. left circumflex: left circumflex is a large-caliber vessel, gives off a large distal pda branch, has a 99% proximal lesion, 50% mid vessel lesion, and a 50% lesion in the om, which is a distal branch.,4. right coronary artery: right coronary artery is a moderate-caliber vessel, dominant, bifurcates into pda and plv branches, has only mild disease. otherwise, no significant stenosis noted.,5. lv: the lvef 50%. inferolateral wall hypokinesis. no significant mitral regurgitation. no gradient across the aortic valve on pullback.,assessment and plan: , st-elevation myocardial infarction with a 99% stenosis of the proximal portion of the left circumflex treated with a 3.5 x 12 mm vision bare-metal stent and a 3.5 x 8 mm vision bare-metal stent. excellent results, 0% residual stenosis. the patient continues to have some residual 50% stenosis in the left circumflex system, some mild disease throughout the other vessels. therefore, we will aggressively treat this patient medically with close followup as an outpatient.

preoperative diagnosis: , foreign body, right foot.,postoperative diagnosis: , foreign body in the right foot.,procedure performed:, excision of foreign body, right foot and surrounding tissue.,anesthesia: , tiva and local.,history:, this 41-year-old male presents to preoperative holding area after keeping himself n.p.o., since mid night for removal of painful retained foreign body in his right foot. the patient works in the electronics/robotics field and relates that he stepped on a wire at work, which somehow got into his shoe. the wire entered his foot. his family physician attempted to remove the wire, but it only became deeper in the foot. the wound eventually healed, but a scar tissue was formed. the patient has had constant pain with ambulation intermittently since the incident occurred. he desires attempted surgical removal of the wire. the risks and benefits of the procedure have been explained to the patient in detail by dr. x. the consent is available on the chart for review.,procedure in detail: , after iv was established by the department of anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position with a safety strap placed across his waist for his protection.,a pneumatic ankle tourniquet was applied about the right ankle over copious amounts of webril for the patient's protection. after adequate iv sedation was administered by the department of anesthesia, a total of 12 cc of 0.5% marcaine plain was used to administer an ankle block. next, the foot was prepped and draped in the usual aseptic fashion. an esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmhg. the foot was lowered into the operative field and the sterile stockinet was reflected. attention was directed to the plantar aspect of the foot where approximately a 5 mm long cicatrix was palpated and visualized. this was the origin and entry point of the previous puncture wound from the wire. this cicatrix was found lateral to the plantar aspect of the first metatarsal between the first and second metatarsals in a nonweightbearing area. next, the xi-scan was draped and brought into the operating room. a #25 gauge needles under fluoroscopy were inserted into the plantar aspect of the foot and three planes to triangulate the wire. next, a #10 blade was used to make approximately a 3 cm curvilinear "s"-shaped incision. next, the #15 blade was used to carry the incision through the subcutaneous tissue. the medial and lateral margins of the incision were undermined. due to the small nature of the foreign body and the large amount of fat on the plantar aspect of the foot, the wires seemed to serve no benefit other then helping with the incision planning. therefore, they were removed. once the wound was opened, a hemostat was used to locate the wire very quickly and the wire was clamped. a second hemostat was used to clamp the wire. a #15 blade was used to carefully transect the fatty tissue around the tip of the hemostats, which were visualized in the base of the wound. the wire quickly came into visualization. it measured approximately 4 mm in length and was approximately 1 mm in diameter. the wire was green colored and metallic in nature. it was removed with the hemostat and passed off as a specimen to be sent to pathology for identification. the wire was found at the level of deep fascia at the capsular level just plantar to the deep transverse intermetatarsal ligament. next, copious amounts of sterile gentamicin impregnated saline was instilled in the wound for irrigation and the wound base was thoroughly cleaned and inspected. next, a #3-0 vicryl was used to throw two simple interrupted deep sutures to remove the dead space. next, #4-0 ethibond was used to close the skin in a combination of simple interrupted and horizontal mattress suture technique. the standard postoperative dressing consisting of saline-soaked owen silk, 4x4s, kling, kerlix, and coban were applied. the pneumatic ankle tourniquet was released. there was immediate hyperemic flush to the digits noted. the patient's anesthesia was reversed. he tolerated the above anesthesia and procedure without complications. the patient was transported via cart to the postanesthesia care unit.,vital signs were stable and vascular status was intact to the right foot. he was given orthowedge shoe. ice was applied behind the knee and his right lower extremity was elevated on to pillows. he was given standard postoperative instructions consisting of rest, ice and elevation to the right lower extremity. he is to be non-weightbearing for three weeks, at which time, the wound will be evaluated and sutures will be removed. he is to follow up with dr. x on 08/22/2003 and was given emergency contact number to call if problems arise. he was given a prescription for tylenol #4, #30 one p.o. q.4-6h. p.r.n., pain as well as celebrex 200 mg #30 take two p.o. q.d. p.c., with 200 mg 12 hours later as a rescue dose. he was given crutches. he was discharged in stable condition.

chief complaint:, itchy rash.,history of present illness: , this 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. no facial swelling. no tongue or lip swelling. no shortness of breath, wheezing, or other associated symptoms. he cannot think of anything that could have triggered this off. there have been no changes in his foods, medications, or other exposures as far as he knows. he states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,past medical history: , negative for chronic medical problems. no local physician. has had previous back surgery and appendectomy, otherwise generally healthy.,review of systems: , as mentioned denies any oropharyngeal swelling. no lip or tongue swelling. no wheezing or shortness of breath. no headache. no nausea. notes itchy rash, especially on his torso and upper arms.,social history: , the patient is accompanied with his wife.,family history: , negative.,medications: , none.,allergies: , toradol, morphine, penicillin, and ampicillin.,physical examination: , vital signs: the patient was afebrile. he is slightly tachycardic, 105, but stable blood pressure and respiratory rate. general: the patient is in no distress. sitting quietly on the gurney. heent: unremarkable. his oral mucosa is moist and well hydrated. lips and tongue look normal. posterior pharynx is clear. neck: supple. his trachea is midline. there is no stridor. lungs: very clear with good breath sounds in all fields. there is no wheezing. good air movement in all lung fields. cardiac: without murmur. slight tachycardia. abdomen: soft, nontender. skin: notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. he noted some on his buttocks as well. remaining of the exam is unremarkable.,ed course: , the patient was treated with epinephrine 1:1000, 0.3 ml subcutaneously along with 50 mg of benadryl intramuscularly. after about 15-20 minutes he states that itching started to feel better. the rash has started to fade a little bit and feeling a lot more comfortable.,impression:, acute allergic reaction with urticaria and pruritus.,assessment and plan: , the patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. he will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. in the meantime, i think he can be managed with some antihistamine over-the-counter. he is responding already to benadryl and the epinephrine that we gave him here. he is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. he is discharged in stable condition.

history of present illness: , this is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent pta of right leg, admitted to the hospital because of swelling of the right hand and left foot. the patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. i was asked to see the patient regarding chronic kidney disease.,past medical history:,1. diabetes mellitus type 2.,2. diabetic nephropathy.,3. chronic kidney disease, stage 4.,4. hypertension.,5. hypercholesterolemia and hyperlipidemia.,6. peripheral vascular disease, status post recent, last week pta of right lower extremity.,social history:, negative for smoking and drinking.,current home medications:, novolog 20 units with each meal, lantus 30 units at bedtime, crestor 10 mg daily, micardis 80 mg daily, imdur 30 mg daily, amlodipine 10 mg daily, coreg 12.5 mg b.i.d., lasix 20 mg daily, ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,review of systems: , the patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. also, she could not urinate and states as soon as they put foley in, 500 ml of urine came out. also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. denies any fever and chills. denies any dysuria, frequency or hematuria. states that the urine output was decreased considerably, and she could not urinate. denies any cough, hemoptysis or sputum production. denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,physical examination:,general: the patient is alert and oriented, in no acute distress.,vital signs: blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. the patient's weight is 105.6 kg.,head: normocephalic.,neck: supple. no jvd. no adenopathy.,chest: symmetric. no retractions.,lungs: clear.,heart: rrr with no murmur.,abdomen: obese, soft, and nontender. no rebound. no guarding.,extremity: she has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,lab tests: , showed that urine culture is negative up to date. the patient's white cell is 12.7, hematocrit 26.1. the patient has 90% segs and 0% bands. serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, bun 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. sed rate was 121. bnp was 851. urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,impression:,1. urinary tract infection.,2. acute gouty attack.,3. diabetes mellitus with diabetic nephropathy.,4. hypertension.,5. hypercholesterolemia.,6. peripheral vascular disease, status post recent pta in the right side.,7. chronic kidney disease, stage 4.,plan: , at this time is i agree with treatment. we will add allopurinol 50 mg daily. this is secondary to the patient is already on colchicine, and also we will discontinue micardis, we will increase lasix to 40 b.i.d., and we will follow with the lab results.

preoperative diagnosis: ,left breast mass with abnormal mammogram.,postoperative diagnosis:, left breast mass with abnormal mammogram.,procedure performed:, needle-localized excisional biopsy of the left breast.,anesthesia:, local with sedation.,complications: , none.,specimen: , breast mass.,disposition: , the patient tolerated the procedure well and was transferred to recovery in stable condition.,intraoperative findings: , the patient had a nonpalpable left breast mass, which was excised and sent to radiology with confirmation that the mass is in the specimen.,brief history:, the patient is a 62-year-old female who presented to dr. x's office with an abnormal mammogram showing a suspicious area on the left breast with microcalcifications and a nonpalpable mass. so the patient was scheduled for a needle-localized left breast biopsy.,procedure:, after informed consent, the risks and benefits of the procedure were explained to the patient. the patient was brought to the operating suite. after iv sedation was given, the patient was prepped and draped in normal sterile fashion. next, a curvilinear incision was made.,after anesthetizing the skin with 0.25% marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. the lesion with needle was then grasped with an allis clamp. using #10 blade scalpel, the specimen was colonized out and sent to radiology for confirmation. next, hemostasis was obtained using electrobovie cautery. the skin was then closed with #4-0 monocryl suture in running subcuticular fashion. steri-strips and sterile dressings were applied. the patient tolerated the procedure well and was sent to recovery in stable condition.

cc:, left hemibody numbness.,hx:, this 44y/o rhf awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. she had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. she coincidentally began listing to the right when walking. she denied any recent colds/flu-like illness or history of multiple sclerosis. she denied symptoms of lhermitte's or uhthoff's phenomena.,meds:, none.,pmh:, 1)bronchitis twice in past year (last 2 months ago).,fhx:, father with htn and h/o strokes at ages 45 and 80; now 82 years old. mother has dm and is age 80.,shx:, denies tobacco/etoh/illicit drug use.,exam:, bp112/76 hr52 rr16 36.8c,ms: unremarkable.,cn: unremarkable.,motor: 5/5 strength throughout except for slowing of right hand fine motor movement. there was mildly increased muscle tone in the rue and rle.,sensory: decreased pp below t2 level on left and some dysesthesias below l1 on the left.,coord: positive rebound in rue.,station/gait: unremarkable.,reflexes: 3+/3 throughout all four extremities. plantar responses were flexor, bilaterally.,rectal exam not done.,gen exam reportedly "normal.",course:, gs, cbc, pt, ptt, esr, serum ssa/ssb/dsdna, b12 were all normal. mri c-spine, 7/145/93, showed an area of decreased t1 and increased t2 signal at the c4-6 levels within the right lateral spinal cord. the lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. lumbar puncture, 7/16/93, revealed the following csf analysis results: rbc 0, wbc 1 (lymphocyte), protein 28mg/dl, glucose 62mg/dl, csf albumin 16 (normal 14-20), serum albumin 4520 (normal 3150-4500), csf igg 4.1mg/dl (normal 0-6.2), csf igg, % total csf protein 15% (normal 1-14%), csf igg index 1.1 (normal 0-0.7), oligoclonal bands were present. she was discharged home.,the patient claimed her symptoms resolved within one month. she did not return for a scheduled follow-up mri c-spine.

history of present illness:, the patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. she states that she has not voided in the last 24 hours as well due to pain. she denies any leaking of fluid, vaginal bleeding, or uterine contractions. she reports good fetal movement. she denies any fevers, chills, or burning with urination.,review of systems: , positive for back pain in her lower back only. her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant. she continues to yell out for requesting pain medication and about how much "it hurts.",past medical history:,1. irritable bowel syndrome.,2. urinary tract infections times three. the patient is unsure if pyelo is present or not.,past surgical history:, denies.,allergies: , no known drug allergies.,medications: , phenergan and zofran twice a day. macrobid questionable.,gyn: , history of an abnormal pap, group b within normal limits. denies any sexually transmitted diseases.,ob history: , g1 is a term spontaneous vaginal delivery without complications, now a 6-year-old. g2 is current. gets her care at lyndhurst.,social history: , denies tobacco and alcohol use. she endorses marijuana use and a history of cocaine use five years ago. upon review of the baptist lab systems, the patient has had multiple positive urine drug screens and as recently as february 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,physical exam:,vital signs: blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees fahrenheit. fetal heart tones are 130s with moderate long-term variability. no paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,general: appears sedated, trashing intermittently, and then falling asleep in mid sentence.,cardiovascular: regular rate and rhythm.,pulmonary: clear to auscultation bilaterally.,back: tender to palpation in her lower back bilaterally, but no cva tenderness.,abdomen: tender to palpation in left lower quadrant. no guarding or rebound. normal bowel sounds.,extremities: scar track marks from bilateral arms.,pelvic: external vaginal exam is closed, long, high, and posterior. stool was felt in the rectum.,labs: , white count is 11.1, hemoglobin is 13.5, platelets are 279. cmp is within normal limits with an ast of 17, alt of 11, and creatinine of 0.6. urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,assessment and plan: ,the patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation. i spoke with dr. x who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to labor and delivery. plans are made for transfer at this time. this was discussed with dr. y who is in agreement with the plan.

physical examination,general appearance: , well developed, well nourished, in no acute distress.,vital signs:, ***,skin: ,inspection of the skin reveals no rashes, ulcerations or petechiae.,heent:, the sclerae were anicteric and conjunctivae were pink and moist. extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. external inspection of the ears and nose showed no scars, lesions, or masses. lips, teeth, and gums showed normal mucosa. the oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,neck: ,supple and symmetric. there was no thyroid enlargement, and no tenderness, or masses were felt.,chest: , normal ap diameter and normal contour without any kyphoscoliosis.,lungs: , auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,cardiovascular: ,there was a regular rate and rhythm without any murmurs, gallops, rubs. the carotid pulses were normal and 2+ bilaterally without bruits. peripheral pulses were 2+ and symmetric.,abdomen: ,soft and nontender with normal bowel sounds. the liver span was approximately 5-6 cm in the right midclavicular line by percussion. the liver edge was nontender. the spleen was not palpable. there were no inguinal or umbilical hernias noted. no ascites was noted.,rectal: ,normal perineal exam. sphincter tone was normal. there was no external hemorrhoids or rectal masses. stool hemoccult was negative. the prostate was normal size without any nodules appreciated (men only).,lymph nodes: , no lymphadenopathy was appreciated in the neck, axillae or groin.,musculoskeletal: , gait was normal. there was no tenderness or effusions noted. muscle strength and tone were normal.,extremities: , no cyanosis, clubbing or edema.,neurologic: ,alert and oriented x 3. normal affect. gait was normal. normal deep tendon reflexes with no pathological reflexes. sensation to touch was normal.

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:

preoperative diagnosis:, recurrent right upper quadrant pain with failure of antacid medical therapy.,postoperative diagnosis: , normal esophageal gastroduodenoscopy.,procedure performed:, esophagogastroduodenoscopy with bile aspirate.,anesthesia: , iv demerol and versed in titrated fashion.,indications: , this 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain. despite antacid therapy, the patient's pain has continued. additional findings were concerning with possibility of a biliary etiology. the patient was explained the risks and benefits of an egd as well as a meltzer-lyon test where upon bile aspiration was performed. the patient agreed to the procedure and informed consent was obtained.,gross findings: , no evidence of neoplasia, mucosal change, or ulcer on examination. aspiration of the bile was done after the administration of 3 mcg of kinevac.,procedure details: , the patient was placed in the supine position. after appropriate anesthesia was obtained, an olympus gastroscope inserted from the oropharynx through the second portion of duodenum. prior to this, 3 mcg of iv kinevac was given to the patient to aid with the stimulation of bile. at this time, the patient as well complained of epigastric discomfort and nausea. this pain was similar to her previous pain.,bile was aspirated with a trap to enable the collection of the fluid. this fluid was then sent to lab for evaluation for crystals. next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted. the gastroesophageal junction was noted at 20 cm. no other evidence of disease was appreciated here. retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient. the patient tolerated the procedure well. we will await evaluation of bile aspirate.

cc: ,motor vehicle-bicycle collision.,hx:, a 5 y/o boy admitted 10/17/92. he was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. first responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. he had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. he was intubated and ventilated in the field, and then transferred to uihc.,pmh/fhx/shx:, unremarkable.,meds:, none,exam:, bp 127/91 hr69 rr30,ms: unconscious and intubated,glasgow coma scale=4,cn: pupils 6/6 fixed. corneal reflex: trace od, absent os. gag present on manipulation of endotracheal tube.,motor/sensory: bilateral decorticate posturing to noxious stimulation (chest).,reflexes: bilaterally.,laceration of mid forehead exposing calvarium.,course:, emergent brain ct scan revealed: displaced fracture of left calvarium. left frontoparietal intraparenchymal hemorrhage. right ventricular collection of blood. right cerebral intraparenchymal hemorrhage. significant mass effect with deviation of the midline structures to right. the left ventricle was compressed with obliteration of the suprasellar cistern. air within the soft tissues in the left infra temporal region. c-spine xr, abdominal/chest ct were unremarkable.,patient was taken to the or emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. he was given mannitol enroute to the or and hyperventilated during and after the procedure. postoperatively he continued to manifest decerebrate posturing . on 11/16/92 he underwent vp shunting with little subsequent change in his neurological status. on 11/23/92 he underwent tracheostomy. on 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. by the time of discharge, 1/14/93, he tracked relatively well od, but had a cn3 palsy os. he had relatively severe extensor rigidity in all extremities (r>l). his tracheotomy was closed prior to discharge. a 11/16/92 brain mri demonstrated infarction in the upper brain stem (particularly in the pons), left cerebellum, right basil ganglia and thalamus.,he was initially treated for seizure prophylaxis with dph, but developed neutropenia, so it was discontinued. he developed seizures within several months of discharge and was placed on vpa (depakene). this decreased seizure frequency but his liver enzymes became elevated and he changed over to tegretol. 10/8/93 brain mri (one year after mva) revealed interval appearance of hydrocephalus, abnormal increased t2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. these findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,he was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. he was averaging 2-3 seizures per day---characterized by extension of bue with tremor and audible cry or laughter---on tegretol and diazepam. in addition he experiences 24-48hour periods of "startle response (myoclonic movement of the shoulders)" with or without stimulation every 6 weeks. he had limited communication skills (sparse speech). on exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.

procedure: , skin biopsy, scalp mole.,indication: ,a 66-year-old female with pulmonary pneumonia, effusion, rule out metastatic melanoma to lung.,procedure note: , the patient's scalp hair was removed with:,1. k-y jelly.,2. betadine prep locally.,3. a 1% lidocaine with epinephrine local instilled.,4. a 3 mm punch biopsy used to obtain biopsy specimen, which was sent to the lab. to control bleeding, two 4-0 p3 nylon sutures were applied, antibiotic ointment on the wound. hemostasis was controlled. the patient tolerated the procedure.,impression:, darkened mole status post punch biopsy, scalp lesion, rule out malignant melanoma with pulmonary metastasis.,plan: , the patient will have sutures removed in 10 days.

history:, a 69-year-old female with past history of type ii diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. the patient was status post coronary artery bypass surgery aortic valve repair at shadyside hospital. the patient subsequently developed cva. she also developed thrombosis of the right arm, which ultimately required right hand amputation. she was stabilized and eventually transferred to healthsouth for further management.,physical examination:,vital signs: pulse of 90 and blood pressure 150/70.,heart: sounds were heard, grade 2/6 systolic murmur at the precordium.,chest: clinically clear.,abdomen: some suprapubic tenderness. evidence of right lower arm amputation.,the patient was started on prevacid 30 mg daily, levothyroxine 75 mcg a day, toprol 25 mg twice a day, zofran 4 mg q.6 h, coumadin dose at 5 mg and was adjusted. she was given a pain control using vicodin and percocet, amiodarone 200 mg a day, lexapro 20 mg a day, plavix 75 mg a day, fenofibrate 145 mg, lasix 20 mg iv twice a day, lantus 50 units at bedtime and humalog 10 units a.c. and sliding scale insulin coverage. wound care to the right heel was supervised by dr. x. the patient initially was fed through ng tube, which was eventually discontinued. physical therapy was ordered. the patient continued to do well. she was progressively ambulated. her meds were continuously adjusted. the patient's insulin was eventually changed from lantus to levemir 25 units twice a day. dr. y also followed the patient closely for left heel ulcer.,laboratory data: , the latest cultures from left heel are pending. her electrolytes revealed sodium of 135 and potassium of 3.2. her potassium was switched to k-dur 40 meq twice a day. her blood chemistries are otherwise closely monitored. inrs were obtained and were therapeutic. throughout her hospitalization, multiple cultures were also obtained. urine cultures grew klebsiella. she was treated with appropriate antibiotics. her detailed blood work is as in the chart. detailed radiological studies are as in the chart. the patient made a steady progress and eventually plans were made to transfer the patient to abc furthermore aggressive rehabilitation.,final diagnoses:,1. atherosclerotic heart disease, status post coronary artery bypass graft.,2. valvular heart disease, status post aortic valve replacement.,3. right arm arterial thrombosis, status post amputation right lower arm.,4. hypothyroidism.,5. uncontrolled diabetes mellitus, type 2.,6. urinary tract infection.,7. hypokalemia.,8. heparin-induced thrombocytopenia.,9. peripheral vascular occlusive disease.,10. paroxysmal atrial fibrillation.,11. hyperlipidemia.,12. depression.,13. carotid stenosis.

admission diagnoses:,1. atypical chest pain.,2. nausea.,3. vomiting.,4. diabetes.,5. hypokalemia.,6. diarrhea.,7. panic and depression.,8. hypertension.,discharge diagnoses:,1. serotonin syndrome secondary to high doses of prozac.,2. atypical chest pain with myocardial infarction ruled out.,3. diabetes mellitus.,4. hypertension.,5. diarrhea resolved.,admission summary: , the patient is a 53-year-old woman with history of hypertension, diabetes, and depression. unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression. she was having chest pains along with significant vomiting and diarrhea. of note, she had a nuclear stress test performed in february of this year, which was normal. she was readmitted to the hospital to rule out myocardial infarction and for further evaluation.,admission physical: , significant for her being afebrile. apparently there was one temperature registered mildly high at 100. her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%. she was tearful. heart: heart sounds were regular. lungs: clear. abdomen: soft. apparently there were some level of restlessness and acathexia. she was also pacing.,admission labs: ,showed cbc with a white count of 16.9, hematocrit of 46.9, platelets 318,000. she had 80% neutrophils, no bands. ua on 05/02 came out negative. chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, alt was 39, ast 38, total bilirubin 0.6. her initial ck came out at 922. ck-mb was low. troponin was 0.04. she had a normal amylase and lipase. previous tsh few days prior was normal. chest x-ray was negative.,hospital course:,1. serotonin syndrome. after reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and cpk. she did not have fever, tremor or hyperreflexia. her cpk improved with iv fluids. she dramatically improved with this discontinuation of her prozac. her white count came back down towards normal. at time of discharge, she was really feeling back to normal.,2. depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago. we discussed this. also, discussed the situation with a psychiatrist who is available on friday and i discussed the situation with the patient. in regards to her medications, we are discontinuing the prozac and she is being reevaluated by dr. x on monday or tuesday. cymbalta has been recommended as a good alternative medication for her. the patient does have a counselor. it is going to be difficult for her to go home alone. i discussed the resources with her. she has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.,3. hypertension. she will continue on her usual medications.,4. diabetes mellitus. she will continue on her usual medications.,5. diarrhea resolved. her electrolyte abnormalities resolved. she had received fluid rehydration.,disposition:, she is being discharged to home. she will stay with a friend for a couple of days. she will be following up with dr. x on monday or tuesday. apparently dr. y has already discussed the situation and the plan with her. she will continue on her usual medications except for discontinuing the prozac.,discharge medications: , include,1. omeprazole 20 mg daily.,2. temazepam 15 mg at night.,3. ativan 1 mg one-half to one three times a day as needed.,4. cozaar 50 daily.,5. prandin 1 mg before meals.,6. aspirin 81 mg.,7. multivitamin daily.,8. lantus 60 units at bedtime.,9. percocet 10/325 one to two at night for chronic pain. she is running out of that, so we are calling a prescription for #10 of those.

chief complaint:, pressure decubitus, right hip.,history of present illness:, this is a 30-year-old female patient presenting with the above chief complaint. she has a history of having had a similar problem last year which resolved in about three treatments. she appears to have residual from spina bifida, thus spending most of her time in a wheelchair. she relates recently she has been spending up to 16 hours a day in a wheelchair. she has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. she is now presenting for evaluation and management of same. denies any chills or fever, any other symptoms.,past medical history:, back closure for spina bifida, hysterectomy, breast reduction, and a shunt.,social history:, she denies the use of alcohol, illicits, or tobacco.,medications:, pravachol, dilantin, toprol, and macrobid.,allergies:, sulfa and latex.,review of systems:, other than the above aforementioned, the remaining ros is unremarkable.,physical examination:,general: a pleasant female with deformity of back.,heent: head is normocephalic. oral mucosa and dentition appear to be normal.,chest: breath sounds equal and present bilateral.,cvs: sinus.,gi: obese, nontender, no hepatosplenomegaly.,extremities: deformity of lower extremities secondary to spina bifida.,skin: she has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue.,plan:, daily applications of acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.,diagnosis:, sequelae of spina bifida; pressure decubitus of right hip area.

preoperative diagnoses:,1. extruded herniated disc, left l5-s1.,2. left s1 radiculopathy (acute).,3. morbid obesity.,postoperative diagnoses:,1. extruded herniated disc, left l5-s1.,2. left s1 radiculopathy (acute).,3. morbid obesity.,procedure performed: , microscopic lumbar discectomy, left l5-s1.,anesthesia: , general.,complications: , none.,estimated blood loss: ,50 cc.,history: , this is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at l5-s1. she has been dealing with these symptoms for greater than three months. she comes to my office with severe pain, left my office and reported to the emergency room where she was admitted for pain control one day before surgery. i have discussed the mri findings with the patient and the potential risks and complications. she was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the emergency room. we discussed the diagnosis and the operative procedure in detail. i have reviewed the potential risks and complications and she had agreed to proceed with the surgery. due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and i have discussed this with her. she is aware that she will have a much larger incision than what is standard and has agreed to accept this.,operative procedure: ,the patient was taken to or #5 at abcd general hospital. while in the hospital gurney, department of anesthesia administered general anesthetic, endotracheal intubation was followed. a jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing. the table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb. once the table was reinforced, the patient was carefully rolled in a prone position on the jackson table with the bony prominences being well padded. a marker was placed in from the back at this time and an x-ray was obtained for incision localization. the back is now prepped and draped in the usual sterile fashion. a midline incision was made over the l5-s1 disc space taking through subcutaneous tissue sharply with a #10 bard-parker scalpel. the lumbar dorsal fascia was then encountered and incised to the left of midline. in the subperiosteal fashion, the musculature was elevated off the lamina at l5 and s1 after facet joint, but not disturbing the capsule. a second marker was now placed and an intraoperative x-ray confirms our location at the l5-s1 disc space. the microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination. a high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the s1 lamina and the inferior edge of the l5 lamina. ligaments and fragments were encountered and removed at this time. the epidural space was now encountered. the s1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a penfield. a small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening. this disc fragment was removed and the nerve root was much more supple, it was carefully retracted. the nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of s1 and l5. at this point, all disc fragments were removed from the epidural space. murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that i can identify. the disc space was now encountered and loose disc fragments were removed from within the disc space. the disc space was then irrigated. the nerve root was then reassessed and found to be quite supple. at this point, the murphy ball was passed into the foramen of l5 and this was patent and also into the foramen of s1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device. at this point, the wound was irrigated copiously and suctioned dry. gelfoam was used to cover the epidural space. the retractors were removed at this point. the fascia was reapproximated with #1 vicryl suture, subcutaneous tissue with #2-0 vicryl suture and steri-strips for curved incision. the patient was transferred to the hospital gurney in supine position and extubated by anesthesia, subsequently transferred to postanesthesia care unit in stable condition.

current history:, a 94-year-old female from the nursing home with several days of lethargy and anorexia. she was found to have evidence of uti. she also has renal insufficiency and digitalis toxicity. she is admitted for further treatment.,past medical history, social history, family history, physical examination can be seen on the admission h&p.,laboratories on admission: , white count 11,700, hemoglobin 12.8, hematocrit 37.2, bun 91, creatinine 2.2, sodium 131, potassium 5.1. digoxin level of 4.1.,hospital course: , the patient was admitted and intravenous fluids and antibiotics were administered. blood cultures were negative. urine cultures were nondiagnostic. renal function improved with creatinine down to 1 at the time of discharge. digoxin was restarted at a lower dose. her condition improved and she is stabilized and transferred back to assisted living in good condition.,primary diagnoses:,1. urinary tract infection.,2. volume depletion.,3. renal insufficiency.,4. digitalis toxicity.,secondary diagnoses:,1. aortic valve stenosis.,2. congestive heart failure.,3. hypertension.,4. chronic anemia.,5. degenerative joint disease.,6. gastroesophageal reflux disease.,procedures:, none.,complications: , none.,discharge condition: , improved and stable.,discharge plan: ,physical activity: with assistance. ,diet: no restriction. ,medications: lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, augmentin 875 mg 1 tablet twice a day for 1 week, nexium 40 mg daily, elavil 10 mg at bedtime, detrol 2 mg twice a day, potassium 10 meq daily and diclofenac 50 mg twice a day. ,follow up: she will see dr. x in the office as scheduled.

preoperative diagnosis:, rotator cuff tear, right shoulder.,postoperative diagnoses:,1. massive rotator cuff tear, right shoulder.,2. near complete biceps tendon tear, right shoulder.,3. chondromalacia of glenohumeral joint, right shoulder.,4. glenoid labrum tear, right shoulder.,procedure performed: ,1. arthroscopy of the arthroscopic glenoid labrum.,2. rotator cuff debridement shaving glenoid and humeral head.,3. biceps tenotomy, right shoulder.,specification: , the entire operative procedure was done in inpatient operating suite, room #1 at abcd general hospital. this was done under interscalene block anesthetic in the modified beachchair position.,history and gross findings: , this is a 61-year-old white male who is dominantly right-handed. he had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention. this was gradually done over a period of time. no specific accident or injury could be seen or pointed. he was refractory to conservative outpatient therapy. after discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,preoperatively, the patient did not have limitation of motion. he had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,intraarticularly, the patient had an 80% biceps tendon tear that was dislocated. his rotator interval was resolved as well as his subscapularis with tearing. the supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe. glenoid labrum had degenerative tear in the inferior surface. gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,operative procedure: , the patient was laid supine upon the operative table. after receiving interscalene block anesthetic by the anesthesia department, he was safely placed in a modified beachchair position. he was prepped and draped in the usual sterile manner. the portals were created outside the end posteriorly and then anteriorly. a full and complete diagnostic arthroscopy was carried out with the above-noted findings. the shaver was placed anteriorly. debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed. debridement was carried out to the end or attachment of the bicep itself.,debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out. debridement was then carried out to the rotator cuff remaining tendon near the tuberosity. no osteophytes were present. because of the massive nature of the tear, the ca ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring. there was concern because of instability that could be present at the end of this.,another portal was created laterally to do all of this. we did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly. we took this back to the level of coracoid base. we released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn. because of this, further debridement was carried out. debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge. care was taken to not to debride deeper than that. this was done prior to the above.,all instrumentation was removed. a pain-buster catheter was placed into a separate anterolateral portal cut to length. interrupted #4-0 nylon was utilized for portal closures. adaptic, 4x4s, abds, elastoplast tape were placed for a compression dressing.,the patient's arm was placed in an arm sling. he was transferred to his cart and to the pacu in apparent satisfactory condition. expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.

mr. xyz forgot his hearing aids at home today and is severely hearing impaired and most of the interview had to be conducted with me yelling at him at the top of my voice. for all these reasons, this was not really under the best circumstances and i had to curtail the amount of time i spent trying to get a history because of the physical effort required in extracting information from this patient. the patient was seen late because he had not filled in the patient questionnaire. to summarize the history here, mr. xyz who is not very clear on events from the past, sustained a work-related injury some time in 1998. at that time, he was driving an 18-wheeler truck. the patient indicated that he slipped off the rear of his truck while loading vehicles to his trailer. he experienced severe low back pain and eventually a short while later, underwent a fusion of l4-l5 and l5-s1. the patient had an uneventful hospital course from the surgery, which was done somewhere in florida by a surgeon, who he does not remember. he was able to return to his usual occupation, but then again had a second work-related injury in may of 2005. at that time, he was required to boat trucks to his rig and also to use a chain-pulley system to raise and lower the vehicles. mr. xyz felt a popping sound in his back and had excruciating low back pain and had to be transported to the nearest hospital. he was mri'ed at that time, which apparently showed a re-herniation of an l5-s1 disc and then, he somehow ended up in houston, where he underwent fusion by dr. w from l3 through s2. this was done on 12/15/2005. initially, he did fairly well and was able to walk and move around, but then gradually the pain reappeared and he started getting severe left-sided leg pain going down the lateral aspect of the left leg into his foot. he is still complaining of the severe pain right now with tingling in the medial two toes of the foot and significant weakness in his left leg. the patient was referred to dr. a, pain management specialist and dr. a has maintained him on opioid medications consisting of norco 10/325 mg for breakthrough pain and oxycodone 30 mg t.i.d. with lunesta 3 mg q.h.s. for sleep, carisoprodol 350 mg t.i.d., and lyrica 100 mg q.daily. the patient states that he is experiencing no side effects from medications and takes medications as required. he has apparently been drug screened and his drug screening has been found to be normal. the patient underwent an extensive behavioral evaluation on 05/22/06 by tir rehab center. at that time, it was felt that mr. xyz showed a degree of moderate level of depression. there were no indications in the evaluation that mr. xyz showed any addictive or noncompliant type behaviors. it was felt at that time that mr. xyz would benefit from a brief period of individual psychotherapy and a course of psychotropic medications. of concern to the therapist at that time was the patient's untreated and unmonitored hypertension and diabetes. mr. xyz indicated at that time, they had not purchased any prescription medications or any of these health-related issues because of financial limitations. he still apparently is not under really good treatment for either of these conditions and on today's evaluation, he actually denies that he had diabetes. the impression was that the patient had axis iv diagnosis of chronic functional limitations, financial loss, and low losses with no axis iii diagnosis. this was done by rhonda ackerman, ph.d., a psychologist. it was also suggested at that time that the patient should quit smoking. despite these evaluations, mr. xyz really did not get involved in psychotherapy and there was poor attendance of these visits, there was no clearance given for any surgical interventions and it was felt that the patient has benefited from the use of ssris. of concern in june of 2006 was that the patient had still not stopped smoking despite warnings. his hypertension and diabetes were still not under good control and the patient was assessed at significant risk for additional health complications including stroke, reduced mental clarity, and future falls. it was felt that any surgical interventions should be put on hold at that time. in september of 2006, the patient was evaluated at baylor college of medicine in the occupational health program. the evaluation was done by a physician at that time, whose report is clearly documented in the record. evaluation was done by dr. b. at present, mr. xyz continues on with his oxycodone and norco. these were prescribed by dr. a two and a half weeks ago and the patient states that he has enough medication left to last him for about another two and a half weeks. the patient states that there has been no recent change in either the severity or the distribution of his pain. he is unable to sleep because of pain and his activities of daily living are severely limited. he spends most of his day lying on the floor, watching tv and occasionally will walk a while. ***** from detailed questioning shows that his activities of daily living are practically zero. the patient denies smoking at this time. he denies alcohol use or aberrant drug use. he obtains no pain medications from no other sources. review of mri done on 02/10/06 shows laminectomies at l3 through s1 with bilateral posterior plates and pedicle screws with granulation tissue around the thecal sac and around the left l4-5 and s1 nerve roots, which appear to be retracted posteriorly. there is a small right posterior herniation at l1-l2.,past medical history:, significant for hypertension, hypercholesterolemia and non-insulin-dependent diabetes mellitus. the patient does not know what medications he is taking for diabetes and denies any diabetes. cabg in july of 2006 with no preoperative angina, shortness of breath, or myocardial infarction. history of depression, lumbar fusion surgery in 2000, left knee surgery 25 years ago.,social history:, the patient is on disability. he does not smoke. he does not drink alcohol. he is single. he lives with a girlfriend. he has minimal activities of daily living. the patient cannot recollect when last a urine drug screen was done.,review of systems:, no fevers, no headaches, chest pain, nausea, shortness of breath, or change in appetite. depressive symptoms of crying and decreased self-worth have been noted in the past. no neurological history of strokes, epileptic seizures. genitourinary negative. gastrointestinal negative. integumentary negative. behavioral, depression.,physical examination:, the patient is short of hearing. his cognitive skills appear to be significantly impaired. the patient is oriented x3 to time and place. weight 185 pounds, temperature 97.5, blood pressure 137/92, pulse 61. the patient is complaining of pain of a 9/10.,musculoskeletal: the patient's gait is markedly antalgic with predominant weightbearing on the left leg. there is marked postural deviation to the left. because of pain, the patient is unable to heel-toe or tandem gait. examination of the neck and cervical spine are within normal limits. range of motion of the elbow, shoulders are within normal limits. no muscle spasm or abnormal muscle movements noted in the neck and upper extremities. head is normocephalic. examination of the anterior neck is within normal limits. there is significant muscle wasting of the quadriceps and hamstrings on the left, as well as of the calf muscles. skin is normal. hair distribution normal. skin temperature normal in both the upper and lower extremities. the lumbar spine curvature is markedly flattened. there is a well-healed central scar extending from t12 to l1. the patient exhibits numerous positive waddell's signs on exam of the low back with inappropriate flinching and wincing with even the lightest touch on the paraspinal muscles. examination of the paraspinal muscles show a mild to moderate degree of spasm with a significant degree of tenderness and guarding, worse on the left than the right. range of motion testing of the lumbar spine is labored in all directions. it is interesting that the patient cannot flex more than 5 in the standing position, but is able to sit without any problem. there is a marked degree of sciatic notch tenderness on the left. no abnormal muscle spasms or muscle movements were noted. patrick's test is negative bilaterally. there are no provocative facetal signs in either the left or right quadrants of the lumbar area. neurological exam: cranial nerves ii through xii are within normal limits. neurological exam of the upper extremities is within normal limits with good motor strength and normal biceps, triceps and brachioradialis reflexes. neurological exam of the lower extremities shows a 2+ right patellar reflex and -1 on the left. there is no ankle clonus. babinski is negative. sensory testing shows a minimal degree of sensory loss on the right l5 distribution. muscle testing shows decreased l4-l5 on the left with extensor hallucis longus +2/5. ankle extensors are -3 on the left and +5 on the right. dorsiflexors of the left ankle are +2 on the left and +5 on the right. straight leg raising test is positive on the left at about 35 . there is no ankle clonus. hoffman's test and tinel's test are normal in the upper extremities.,respiratory: breath sounds normal. trachea is midline.,cardiovascular: heart sounds normal. no gallops or murmurs heard. carotid pulses present. no carotid bruits. peripheral pulses are palpable.,abdomen: hernia site is intact. no hepatosplenomegaly. no masses. no areas of tenderness or guarding.,impression:,1. post-laminectomy low back syndrome.,2. left l5-s1 radiculopathy.,3. severe cognitive impairment with minimal ***** for rehabilitation or return to work.,4. opioid dependence for pain control.,treatment plan:, the patient will continue on with his medications prescribed by dr. chang and i will see him in two weeks' time and probably suggest switching over from oxycontin to methadone. i do not think this patient is a good candidate for spinal cord stimulation due to his grasp of exactly what is happening and his cognitive impairment. i will get a behavioral evaluation from mr. tom welbeck and refer the patient for ongoing physical therapy. the prognosis here for any improvement or return to work is zero.

preoperative diagnoses: , phimosis and adhesions.,postoperative diagnoses: ,phimosis and adhesions.,procedures performed: , circumcision and release of ventral chordee.,anesthesia: ,local mac.,estimated blood loss: , minimal.,fluids: , crystalloid. the patient was given antibiotics preop.,brief history: , this is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin. the patient had buried penis with significant obesity issues in the suprapubic area. options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, pe, and cva risks were discussed. the patient had discussed this issue with dr khan and had been approved to get off of the plavix. consent had been obtained. risk of scarring, decrease in penile sensation, and unexpected complications were discussed. the patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc. consent was obtained.,description of procedure: ,the patient was brought to the or. anesthesia was applied. the patient was placed in supine position. the patient was prepped and draped in usual sterile fashion. local mac anesthesia was applied. after draping, 17 ml of mixture of 0.25% marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block. the patient had significant phimosis and slight ventral chordee. using marking pen, the excess foreskin was marked off. using a knife, the ventral chordee was released. the urethra was intact. the excess foreskin was removed. hemostasis was obtained using electrocautery. a 5-0 monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done. the patient tolerated the procedure well. there was excellent hemostasis. the penis was straight. vaseline gauze and kerlix were applied. the patient was brought to the recovery in stable condition. plan was for removal of the dressing tomorrow. okay to shower after 48 hours.

procedure performed: , excisional breast biopsy with needle localization.,anesthesia:, general.,procedure: , after informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance. i reviewed the localizing films with the radiologist, and the patient was then brought to the operative suite and placed supine on the operating table. general endotracheal anesthesia was induced without incident. the patient was prepped and draped in the usual sterile manner.,the skin overlying the needle tip was incised in a curvilinear fashion. dissection down to the needle tip was performed using a combination of metzenbaum scissors and bovie electrocautery. every attempt was made to get approximately 1 cm of normal tissue around the lesion. the wire was released and the lesion having been excised was removed from the wound and sent to radiology for confirmation of excision. the wound was copiously irrigated with sterile water, and hemostasis was obtained using bovie electrocautery. once radiology called and confirmed complete excision of the mass, the skin incision was approximated with 4-0 vicryl in a subcuticular fashion. the skin was prepped with benzoin and steri-strips were applied. a dressing was then applied. all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.

final diagnoses,1. morbid obesity, status post laparoscopic roux-en-y gastric bypass. ,2. hypertension. ,3. obstructive sleep apnea, on cpap.,operation and procedure: , laparoscopic roux-en-y gastric bypass.,brief hospital course summary: ,this is a 30-year-old male, who presented recently to the bariatric center for evaluation and treatment of longstanding morbid obesity and associated comorbidities. underwent standard bariatric evaluation, consults, diagnostics, and preop medifast induced weight loss in anticipation of elective bariatric surgery. ,taken to the or via same day surgery process for elective gastric bypass, tolerated well, recovered in the pacu, and sent to the floor for routine postoperative care. there, dvt prophylaxis was continued with subcu heparin, early and frequent mobilization, and scds. pca was utilized for pain control, efficaciously, he utilized the cpap, was monitored, and had no new cardiopulmonary complaints. postop day #1, labs within normal limits, able to clinically start bariatric clear liquids at 2 ounces per hour, this was tolerated well. he was ambulatory, had no cardiopulmonary complaints, no unusual fever or concerning symptoms. by the second postoperative day, was able to advance to four ounces per hour, tolerated this well, and is able to discharge in stable and improved condition today. he had his drains removed today as well.,discharge instructions: , include re-appointment in the office in the next week, call in the interim if any significant concerning complaints. scripts left in the chart for omeprazole and lortab. med rec sheet completed (on no meds). he will maintain bariatric clear liquids at home, goal 64 ounces per day, maintain activity at home, but no heavy lifting or straining. can shower starting tomorrow, drain site care and wound care reviewed. he will re-appoint in the office in the next week, certainly call in the interim if any significant concerning complaints.