transcription,medical_specialty
"preoperative diagnosis:,  refractory pneumonitis.,postoperative diagnosis: , refractory pneumonitis.,procedure performed: , bronchoscopy with bronchoalveolar lavage.,anesthesia: , 5 mg of versed.,indications: , a 69-year-old man status post trauma, slightly prolonged respiratory failure status post tracheostomy, requires another bronchoscopy for further evaluation of refractory pneumonitis.,procedure: , the patient was sedated with 5 mg of versed that was placed on the endotracheal tube.  bronchoscope was advanced.  both right and left mainstem bronchioles and secondary and tertiary bronchioles were cannulated sequentially, lavaged out.  relatively few tenacious secretions were noted.  these were lavaged out.  specimen collected for culture.  no obvious other abnormalities were noted.  the patient tolerated the procedure well without complication.",36
"subjective:,  mom brings the patient in today for possible ear infection.  he is complaining of left ear pain today.  he was treated on 04/14/2004, with amoxicillin for left otitis and mom said he did seem to get better but just started complaining of the left ear pain today.  he has not had any fever but the congestion has continued to be very thick and purulent.  it has never really resolved.  he has a loose, productive-sounding cough but not consistently and not keeping him up at night.  no wheezing or shortness of breath.,past medical history:,  he has had some wheezing in the past but nothing recently.,family history: , all siblings are on antibiotics for ear infections and uris.,objective:,general:  the patient is a 5-year-old male.  alert and cooperative.  no acute distress.,neck:  supple without adenopathy.,heent:  ear canals clear.  tms, bilaterally, have distorted light reflexes but no erythema.  gray in color.  oropharynx pink and moist with a lot of postnasal discharge.  nares are swollen and red.  thick, purulent drainage.  eyes are a little puffy.,chest:  respirations regular, nonlabored.,lungs:  clear to auscultation throughout.,heart:  regular rhythm without murmur.,skin:  warm, dry, pink.  moist mucus membranes.  no rash.,assessment:,  ongoing purulent rhinitis.  probable sinusitis and serous otitis.,plan:,  change to omnicef two teaspoons daily for 10 days.  frequent saline in the nose.  also, there was some redness around the nares with a little bit of yellow crusting.  it appeared to be the start of impetigo, so hold off on the rhinocort for a few days and then restart.  use a little neosporin for now.",14
"preoperative diagnosis: , left axillary adenopathy.,postoperative diagnosis: , left axillary adenopathy.,procedure: , left axillary lymph node excisional biopsy.,anesthesia:,  lma.,indications: , patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  note, she refused her cmf adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  patient has been following with dr. diener and dr. wilmot.  i believe that genetic counseling had been recommended to her and obviously the cmf was recommended, but she declined both.  she presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  i recommended that she have this lymph node removed.  the procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,technique: , patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with betadine solution, draped in a sterile fashion.  an incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  i was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  the lymph node was excised in its entirety.  the wound was irrigated.  the lymph node sent to pathology.  the wound was then closed.  hemostasis was assured and the patient was taken to recovery room in stable condition.",36
"reason for consultation:,  cardiomyopathy and hypotension.,history of present illness:,  i am seeing the patient upon the request of dr. x.  the patient is very well known to me, an 81-year-old lady with dementia, a native american with coronary artery disease with prior bypass, reduced lv function, recurrent admissions for diarrhea and hypotension several times in november and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  because of her pre-existing coronary artery disease and cardiomyopathy with ef of about 30%, we were consulted to evaluate the patient.  the patient denies any chest pain or chest pressure.  denies any palpitations.  no bleeding difficulty.  no dizzy spells.,review of systems:,constitutional:  no fever or chills.,eyes:  no visual disturbances.,ent:  no difficulty swallowing.,cardiovascular:  basically, no angina or chest pressure.  no palpitations.,respiratory:  no wheezes.,gi:  no abdominal pain, although she had diarrhea.,gu:  no specific symptoms.,musculoskeletal:  have sores on the back.,neurologic:  have dementia.,all other systems are otherwise unremarkable as far as the patient can give me information.,past medical history:,1.  positive for coronary artery disease for about two to three years.,2.  hypertension.,3.  anemia.,4.  chronic renal insufficiency.,5.  congestive heart failure with ef of 25% to 30%.,6.  osteoporosis.,7.  compression fractures.,8.  diabetes mellitus.,9.  hypothyroidism.,past surgical history:,1.  coronary artery bypass grafting x3 in 2008.,2.  cholecystectomy.,3.  amputation of the right second toe.,4.  icd implantation.,current medications at home:,1.  amoxicillin.,2.  clavulanic acid or augmentin every 12 hours.,3.  clopidogrel 75 mg daily.,4.  simvastatin 20 mg daily.,5.  sodium bicarbonate 650 mg twice daily.,6.  gabapentin 300 mg.,7.  levothyroxine once daily.,8.  digoxin 125 mcg daily.,9.  fenofibrate 145 mg daily.,10.  aspirin 81 mg daily.,11.  raloxifene once daily.,12.  calcium carbonate and alendronate.,13.  metoprolol 25 mg daily.,14.  brimonidine ophthalmic once daily.,allergies: , she has no known allergies.,family history: ",4
"history of present illness:  this is a 91-year-old female who was brought in by family.  apparently, she was complaining that she felt she might have been poisoned at her care facility.  the daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  the patient apparently had a little bit of dry heaves, but no actual vomiting.  she had just finished eating dinner.  no one else in the facility has been ill.,past medical history: remarkable for previous abdominal surgeries.  she has a pacemaker.  she has a history of recent collarbone fracture.,review of systems:  very difficult to get from the patient herself.  she seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  she initially stated that everything was wrong, but could not specify any specific complaints.  denies chest pain, back pain, or abdominal pain.  denies any extremity symptoms or complaints.,social history:  the patient is a nonsmoker.  she is accompanied here with daughter who brought her over here.  they were visiting the patient when this episode occurred.,medications:  please see list.,allergies:  none.,physical examination:  vital signs:  the patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  general:  the patient is an elderly frail looking little lady lying on the gurney.  she is awake, alert, and not really wanted to answer most of the questions i asked her.  she does have a tremor with her mouth, which the daughter states has been there for ""many years"".  heent:  eye exam is unremarkable.  oral mucosa is still moist and well hydrated.  posterior pharynx is clear.  neck:  supple.  lungs:  actually clear with good breath sounds.  there are no wheezes, no rales, or rhonchi.  good air movement.  cardiac:  without murmur.  abdomen:  soft.  i do not elicit any tenderness.  there is no abdominal distention.  bowel sounds are present in all quadrants.  skin:  skin is without rash or petechiae.  there is no cyanosis.  extremities:  no evidence of any trauma to the extremities.,emergency department course:  i had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of ativan intramuscularly.  after about half an hour, i came back to talk to the patient and the family, the patient states that she feels better.  family states she seems more calm.  they do not want to pursue any further workup at this time.,impression:  acute episode of agitation.,plan:  at this time, i had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  the patient herself has good vital signs.  she does not seem to have any specific acute process going on and seemed to feel comfortable after the ativan was given, a small quantity was given to the patient.  family and daughter specifically did not want to pursue any workup at this point, which at this point i think is reasonable and we will have her follow up with abc.  she is discharged in stable condition.",11
"history of present illness: , this 40-year-old white single man was hospitalized at xyz hospital in the mental health ward, issues were filled up by his sister and his mother.  the issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother.  he has been in outpatient therapy with jeffrey silverberg for the past 10 years and mr. silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,the history includes the fact that the patient is the 3rd of 4 children.  a brother who is approximately 8 years older, sexually abused brother who is 4 years older.  the brother who is 8 years older lives in california and will contact the family, has had minimal contact for many years.,that brother in california is gay.  the brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis.  he said, he told his mother several years ago, but she did nothing about it.,the patient finished high school and with some struggle completed college at the university of houston.  he has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion.  she has been concerned about patient's behavior and was instrumental in having him committed.,reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,he had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,he states he injured his back about 10 yeas ago.  he told he had disk problems but never had surgery.  he subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,he has been on a variety of different medications including celexa 40 mg and add medication different times, and reportedly has used amphetamines in the past, although he denies it at this time.  he minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,he has never been psychiatrically hospitalized before.,mental status examination:,  revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment.  he says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened.  the brother has a child and wife became very upset with him.,normocephalic.  pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded.  his affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,recent past memory were intact.,diagnoses:,axis i:  major depression rule out substance abuse.,axis ii:  deferred at this time.,axis iii:  noncontributory.,axis iv:  family financial and social pressures.,axis v:  global assessment of functioning 40.,recommendation:,  the patient will be hospitalized to assess.,along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree.  he says he has had several part time jobs, but never been able to sustain employment, although he would like to.",4
"indication: ,  rectal bleeding, constipation, abnormal ct scan, rule out inflammatory bowel disease.,premedication: ,see procedure nurse ncs form.,procedure:  ,",36
"preoperative diagnoses:,1.  nonfunctioning inflatable penile prosthesis.,2.  peyronie's disease.,postoperative diagnoses:,1.  nonfunctioning inflatable penile prosthesis.,2.  peyronie's disease.,procedure performed: , ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis ams700.,anesthesia:,  general lma.,specimen: , old triple component inflatable penile prosthesis.,procedure:  ,this is a 64-year-old male with prior history of peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,operative procedure: , after informed consent, the patient was brought to the operative suite and placed in the supine position.  general endotracheal intubation was performed by the anesthesia department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra.  the bladder was subsequently drained with a red robinson catheter.  at that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space.  care was maintained to avoid all bleeding as possible secondary to the fact that we could not use bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture.  at that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies.  attention was taken then to the tubing, going up to the reservoir in the right lower quadrant.  this was dissected out bluntly and sharply with metzenbaum scissors and monopolar used for hemostasis.  at this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis.  as we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery.  at that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum.  this was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 prolene stay ties, staying lateral and anterior on the corporal body.  the corporal body was opened up and the cylinder was removed from the right side without difficulty.  however, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures.  this was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body.  the left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted.  after removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen.  both corporal bodies were then dilated with the pratt dilators.  these were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces.  at this point, using the farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally.  he had an 18 cm with rear tips in place, which were removed.  we decided to go ahead to and use another 18 cm inflatable penile prosthesis.  confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest.  we felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm.  at this point, we went ahead and placed the right cylinder using the farlow device and the keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty.  attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders.  this then forced us to down size to the 1 cm rear tips, which slipping very easily with the farlow device through the glans penis.  there was no crossover and no violation of the tunica albuginea.  the rear tips were then placed without difficulty and our corporotomies were closed with #2-0 pds in a running fashion.  ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants.  at that point, the wound was copiously irrigated and the device was inflated multiple times.  there was a very good fit and we had a very good result.  at that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution.  this was held in place with a babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump.  please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty.  the entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated.  after completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result.  at that point, after irrigation again of the space, the area was simply dry and hemostatic.  the soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers.  the soft tissue and the skin was then reapproximated with staples.  please also note that prior to the skin closure, a jackson-pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours.  this was also sutured in place with nylon.  sterile dressing was applied.  light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally.  coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine.  no foley catheter was used or placed.,the patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition.  he will be admitted overnight to the service of dr. mcdevitt.  cardiology will be asked to consult with dr. stomel for a pacer placement and he will be placed on the telemetry floor and kept on iv antibiotics.",36
"preoperative diagnosis: , complex right lower quadrant mass with possible ectopic pregnancy.,postoperative diagnoses:,1.  right ruptured tubal pregnancy.,2.  pelvic adhesions.,procedure performed:,1.  dilatation and curettage.,2.  laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,anesthesia:  ,general.,estimated blood loss:  ,less than 100 cc.,complications: , none.,indications: , the patient is a 25-year-old african-american female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  she does have a slowly increasing beta hcg starting at 500 to 849 and the max to 900.  ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  it was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,findings: , on bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  there were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  the cervical os appeared parous.,laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  there were some pelvic adhesions in the right abdominal wall as well.  the left fallopian tube and ovary and uterus appeared normal.  there was no evidence of endometriosis.  there was a small amount of blood in the posterior cul-de-sac.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  the bimanual exam was performed, which revealed the above findings.  a weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  the cervix was then serially dilated using hank dilators up to a #10.  a sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  the tissue was sent to pathology for evaluation.  the uterine elevator was then placed in the patient's cervix.  gloves were changed.  the attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  while tenting up the abdominal wall, the veress needle was placed without difficulty.  the abdomen was then insufflated with appropriate volume and flow of co2.  the #11 step trocar was then placed without difficulty in abdominal wall.  the placement was confirmed with a laparoscope.  it was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  the above findings were then noted.  because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  a #12 step trocar port was placed under direct visualization.  using a grasper, nezhat-dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  this was removed with the gallbladder grasper through the right lateral port site.  there was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  partial salpingectomy was therefore performed.  this was done using the ligasure.  the ligasure was clamped across the portion of the tube including distal tube and ligated and transected.  good hemostasis was obtained in all of the right adnexal structures.  the pelvis was then copiously suction irrigated.  the area again was then visualized and again found to be hemostatic.  the instruments were then removed from the patient's abdomen under direct visualization.  the abdomen was then desufflated and the #11 step trocar was removed.  the incisions were then repaired with #4-0 undyed vicryl and dressed with steri-strips.  the uterine elevator was removed from the patient's vagina.,the patient tolerated the procedure well.  the sponge, lap, and needle count were correct x2.  she will follow up postoperatively as an outpatient.",36
"preoperative diagnoses: , left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,postoperative diagnoses:,  left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,procedures:  ,1.  open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  closed reduction casting of the right forearm.,anesthesia: , surgery performed under general anesthesia.  local anesthetic was 10 ml of 0.5% marcaine.,tourniquet time: , on the left was 29 minutes.,complications:  ,there were no intraoperative complications.,drains: , none.,specimens: , none.,history and physical:  ,the patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  the patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  after the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  at that same time, the patient's mildly angulated radial shaft fracture will be reduced.  this was explained to the father.  the risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  all questions were answered.  the father agreed to the above plan.,procedure in detail: , the patient was taken to the operating room and placed supine on the operating room table.  general anesthesia was then administered.  the patient received ancef preoperatively.  the left upper extremity was then prepped and draped in the standard surgical fashion.  attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  it was decided at this time that she would need open reduction.  the arm was wrapped in esmarch prior to inflation of the tourniquet to 250 mmhg.  the esmarch was then removed.  an incision was then made.  care was taken to avoid any injury to the ulnar nerve.  the medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  this was easily removed.  the ulnar nerve was also identified, and appeared to be intact.  the medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  after fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  the wound was then irrigated with normal saline and closed using 2-0 vicryl and 4-0 monocryl.  the wound was clean and dry, dressed with steri-strips and xeroform.  the area was infiltrated with 0.5% marcaine.  the patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  the tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  the final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  the patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,postoperative plan: , the patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  the father was made aware of the intraoperative findings.  all questions answered.",36
"preoperative diagnosis:,  obstructive sleep apnea.,postoperative diagnosis:  ,obstructive sleep apnea.,procedure performed:,1.  tonsillectomy.,2.  uvulopalatopharyngoplasty.,anesthesia:,  general endotracheal tube.,blood loss: , approximately 50 cc.,indications: , the patient is a 41-year-old gentleman with a history of obstructive sleep apnea who has been using cpap, however, he was not tolerating used of the machine and requested a surgical procedure for correction of his apnea.,procedure: , after all risks, benefits, and alternatives have been discussed with the patient, informed consent was obtained.  the patient was brought to the operative suite where he was placed in supine position and general endotracheal tube intubation was delivered by the department of anesthesia.  the patient was rotated 90 degrees away and a shoulder roll was placed and a mcivor mouthgag was inserted into the oral cavity.  correct inspection and palpation did not reveal evidence of a bifid uvula or submucosal clots.  attention was directed first to the right tonsil in which a curved allis forceps was applied to the superior pole.  the needle-tip bovie cautery was used to incise the mucosa of the anterior tonsillar pillar.  once the tonsillar pillar was identified and the superior pole was released, the curved forceps with a straight allis forceps and the dissection was carried down inferiorly, dissecting the tonsil free from all fascial attachments.  once the tonsil was delivered from the oral cavity, hemostasis was obtained within the tonsillar fossa utilizing suction cautery.,attention was then directed over to the left tonsil in which a similar procedure was performed.  once all bleeding was controlled, the mucosa of both the hard and soft palate was anesthetized with a mixture of 1% lidocaine and 1:50000 epinephrine solution.  now attention was directed to the posterior pillars.  a hemostat was used to clamp the posterior pillar, which was then taken down with metzenbaum scissors.  the posterior pillar was then approximated to the anterior pillar with the use of #3-0 pds suture so as to create a box shaped soft palate.  now, the uvula was reflected onto the soft palate and #12 blade scalpel was used to incise the mucosa of the soft palate extending down onto the uvula.  the mucosa was dissected off with the use of potts scissors.  now the uvula was reflected onto the soft palate and sutured down in place with use of #3-0 pds suture approximated with deep muscle layers.  now the mucosa of the soft palate and the uvula were approximated with interrupted #3-0 pds sutures.  finally, #4-0 vicryl sutures were placed intermittently between the pds to further secure the uvula, which had been reflected onto the soft palate.  a final #3-0 pds suture was used to further approximate the anterior and posterior tonsil pillars.  final inspection did not reveal any further bleeding.  the mouth was then irrigated with saline and suctioned.  at this point, the procedure was complete.  he was awakened and taken to recovery room in stable condition.  he will be admitted as an observation patient to the telemetry floor for routine postoperative management.  of note, iv decadron was administered during the procedure.",36
"reason for examination:  face asleep.,comparison examination:  none.,technique:  multiple axial images were obtained of the brain.  5 mm sections were acquired.  2.5-mm sections were acquired without injection of intravenous contrast.  reformatted sagittal and coronal images were obtained.,discussion:  no acute intracranial abnormalities appreciated.  no evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections.  no cortical based abnormalities appreciated.  the sinuses are clear.  no acute bony abnormalities identified.,preliminary report given to emergency room at conclusion of exam by dr. xyz.,impression:  no acute intracranial abnormalities appreciated.,",31
"preoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy.,2.  residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 with probable instability.,postoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy.,2.  residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 secondary to facet arthropathy with scar tissue.,3.  no evidence of instability.,operative procedure performed,1.  bilateral c3-c4, c4-c5, c5-c6, and c6-c7 medial facetectomy and foraminotomy with technical difficulty.,2.  total laminectomy c3, c4, c5, and c6.,3.  excision of scar tissue.,4.  repair of dural tear with prolene 6-0 and tisseel.,fluids:,  1500 cc of crystalloid.,urine output: , 200 cc.,drains: , none.,specimens: , none.,complications: , none.,anesthesia:,  general endotracheal anesthesia.,estimated blood loss:,  less than 250 cc.,indications for the operation:  ,this is the case of a very pleasant 41 year-old caucasian male well known to me from previous anterior cervical discectomy and posterior decompression.  last surgery consisted of four-level decompression on 08/28/06.  the patient continued to complain of posterior neck pain radiating to both trapezius.  review of his mri revealed the presence of what still appeared to be residual lateral recess stenosis.  it also raised the possibility of instability and based on this i recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial.  based on this, i did total decompression by removing the lamina of c3 through c6 and doing bilateral medial facetectomy and foraminotomy at c3-c4, c4-c5, c5-c6, and c6-c7 with no spinal instrumentation.  operation and expected outcome risks and benefits were discussed with him prior to the surgery.  risks include but not exclusive of bleeding and infection.  infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection.  there is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord.  this may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma.  there is also the risk of a dural tear with its attendant problems of csf leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis.  this too may require return to the operating room for evacuation of said pseudomeningocele and repair.  the patient understood the risk of the surgery.  i told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,description of procedure: , the patient was brought to the operating room, awake, alert, not in any form of distress.  after smooth induction and intubation, a foley catheter was inserted.  monitoring leads were also placed by premier neurodiagnostics for both ssep and emg monitoring.  the sseps were normal, and the emgs were silent during the entire case.  after completion of the placement of the monitoring leads, the patient was then positioned prone on a wilson frame with the head supported on a foam facial support.  shave was then carried out over the occipital and suboccipital region.  all pressure points were padded.  i proceeded to mark the hypertrophic scar for excision.  this was initially cleaned with alcohol and prepped with duraprep.,after sterile drapes were laid out, incision was made using a scalpel blade #10.  wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar.  dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of c2 was then identified.  there was absence of the spinous process of c3, c4, c5, and c6, but partial laminectomy was noted; removal of only 15% of the lamina.  with this completed, we proceeded to do a total laminectomy at c3, c4, c5, and c6, which was technically difficult due to the previous surgery.  there was also a dural tear on the right c3-c4 space that was exposed and repaired with prolene 6-0 and later with tisseel.  by careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at c3-c4, c4-c5, c5-c6, and c6-c7.  there was significant epidural bleeding, which was carefully coagulated.  at two points, i had to pack this with small pieces of gelfoam.  after repair of the dural tear, valsalva maneuver showed no evidence of any csf leakage.  area was irrigated with saline and bacitracin and then lined with tisseel.  the wound was then closed in layers with vicryl 0 simple interrupted sutures to the fascia; vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch.  the patient was extubated and transferred to recovery.",36
"preoperative diagnosis: , left distal both-bone forearm fracture.,postoperative diagnosis: , left distal both-bone forearm fracture.,procedure:,  closed reduction with splint application with use of image intensifier.,indications: , mr. abc is an 11-year-old boy who sustained a fall on 07/26/2008.  evaluation in the emergency department revealed both-bone forearm fracture.  considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  after discussion with parents, verbal and written consent was obtained.,description of procedure:  ,the patient was induced with propofol for conscious sedation via the emergency department staff.  after it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  the patient was aroused from anesthesia and tolerated the procedure well.  post-reduction plain films revealed some anterior displacement of the distal fragment.  at this time, it was determined this fracture proved to be unstable.,disposition: , after review of the reduction films, it appears that there is some element of fracture causing displacement.  we will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,",36
"chief complaint: , testicular pain.,history of present illness:,  the patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  he was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  because of this, they took him to emergency department, at which time, he had no swelling noted initially, but very painful.  he had no voiding or stooling problems.  no nausea, vomiting or fever.  family denies trauma or dysuria.  at that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  he has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  he has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  he has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  he is on no medications and he is here for evaluation.,past medical history:,  the patient has no known allergies.  he is term delivery via spontaneous vaginal delivery.  he has had no problems or hospitalizations with circumcision.,past surgical history: , he has had no previous surgeries.,review of systems:,  all 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,immunizations: , up-to-date.,family history: , the patient lives at home with both parents who are spanish speaking.  he is not in school.,medications:,  he is on no medications.,physical examination:,vital signs:  on physical exam, weight is 15.9 kg.,general:  the patient is a cooperative little boy.,heent:  normal head and neck exam.  no oral or nasal discharge.,neck:  without masses.,chest:  without masses.,lungs:  clear.,cardiac:  without murmurs or gallops.,abdomen:  soft.  no masses or tenderness.  his scrotum did not have any swelling at the present time.  there was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  no palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  his left testis was slightly harder than the right, but this was not very significant.,extremities:  he had full range of motion in all 4 extremities.,skin:  warm, pink, and dry.,neurologic:  grossly intact.,laboratory data: , ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  this is personally reviewed by me.  the right was normal.  no masses were appreciated.  there was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,assessment/plan: , the patient has a possibly torsion detorsion versus other acute testicular problem.  if the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  i discussed the pre and postsurgical care with the parents.  procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  the parents understand and wished to proceed.  we will schedule this later today emergently.",11
"chief complaint: , this is a previously healthy 45-year-old gentleman.  for the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  on the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where dr. xyz noted an incarcerated umbilical hernia.  he was able to reduce this, with relief of pain.  he is now being admitted for definitive repair.,past medical history: , significant only for hemorrhoidectomy.  he does have a history of depression and hypertension.,medications: , his only medications are ziac and remeron.,allergies:,  no allergies.,family history: , negative for cancer.,social history:,  he is single.  he has 2 children.  he drinks 4-8 beers per night and smokes half a pack per day for 30 years.  he was born in salt lake city.  he works in an electronic assembly for harmony music.  he has no history of hepatitis or blood transfusions.,physical examination:,general:  examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,heent:  no scleral icterus.,neck:  no cervical, supraclavicular, or axillary adenopathy.,lungs:  clear.,heart:  regular.  no murmurs or gallops.,abdomen:  as noted, obese with mildly visible bulging in the umbilicus at the superior position.  with gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,diagnostic studies:  ,normal sinus rhythm on ekg, prolonged qt.  chest x-ray was negative.  the abdominal x-rays were read as being negative.  his electrolytes were normal.  creatinine was 0.9.  white count was 6.5, hematocrit was 48, and platelet count was 307.,assessment and plan:,  otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.",14
"preoperative diagnoses,1.  end-stage renal disease.,2.  left subclavian vein occlusion.,3.  status post chronic tracheostomy.,4.  status post coronary artery bypass grafting.,5.  right subclavian vein stenosis.,postoperative diagnoses,1.  end-stage renal disease.,2.  left subclavian vein occlusion.,3.  status post chronic tracheostomy.,4.  status post coronary artery bypass grafting.,5.  right subclavian vein stenosis.,operative procedure,creation of autologous right brachiobasilic arteriovenous fistula - first stage.,indications for the procedure,this patient has a known left subclavian vein occlusion.  the right subclavian vein has an estimated 50% stenosis.  the patient has a catheter traversed in the right innominate vein.  the right basilic vein was judged to be suitable for usage on vein mapping.,operative findings,the basilic vein was of an adequate size, but somewhat sclerotic.  a first stage autologous right brachiobasilic arteriovenous fistula was created.  a grade 2 was felt at completion.,operative procedure in detail,after informed consent was obtained, the patient was taken to the operating room.  the patient was placed in the supine position.  the patient received regional nerve block.  the patient also received intravenous sedation.  the right arm was prepped and draped in the usual sterile fashion.  we used ultrasound to locate the basilic vein at the cubital fossa.,a small transverse incision was made slightly above the basilic vein.  the basilic vein was identified and immobilized.  the basilic vein was of a good size, but somewhat sclerotic.  the underlying fascia was incised and the brachial artery was identified and immobilized.  the brachial artery was normal.  we then divided the basilic vein distally.  the distal end was ligated using silk suture.  the brachial artery was clamped proximally and distally.  a small longitudinal arteriotomy was made in the brachial artery.  we did not give heparin.  the end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 prolene suture.  ,just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  flow was then established.  a grade 2 was felt in the outflow basilic fistula.  hemostasis was secured.  the wound was then closed in layers using interrupted pds sutures for the fascia and a running 4-0 monocryl subcuticular suture for the skin.  a sterile dry dressing was applied.,the patient tolerated the procedure well.  there were no operative complications.  the sponge, instrument, and needle counts were correct at the end of the case.  i was present and participated in all aspects of the procedure.  the patient was transferred to the recovery room in satisfactory condition.",36
"procedures performed: , c5-c6 anterior cervical discectomy, allograft fusion, and anterior plating.,estimated blood loss: , 10 ml.,clinical note: , this is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  we decided go ahead with anterior cervical discectomy at c5-c6 and fusion.  the risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,description of procedure:  ,the patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  the patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  he had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  the tape was placed and his arms were well padded.  he was prepped and draped in a sterile fashion.  a linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  we separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  we then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  we placed caspar retractors for medial and lateral exposure over the c5-c6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  we then marked the disc space.  we then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  we then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  we took down posterior longitudinal ligament as well.  we incised the 6-mm cornerstone bone.  we placed a 6-mm parallel medium bone nicely into the disc space.  we then sized a 23-mm plate.  we inserted the screws nicely above and below.  we tightened down the lock-nuts.  we irrigated the wound.  we assured hemostasis using bone wax prior to placing the plate.  we then assured hemostasis once again.  we reapproximated the platysma using 3-0 vicryl in a simple interrupted fashion.  the subcutaneous level was closed using 3-0 vicryl in a simple buried fashion.  the skin was closed with 3-0 monocryl in a running subcuticular stitch.  steri-strips were applied.  dry sterile dressing with telfa was applied over this.  we obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  i was present as a primary surgeon throughout the entire case.",36
"reason for exam: , pregnant female with nausea, vomiting, and diarrhea.,findings: , the uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  a yolk sac is visualized.  what appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,please note however that no fetal heart tones are seen.  however, fetal heart tones would be expected at this age.,the right ovary measures 3.1 x 1.6 x 2.3 cm.  the left ovary measures 3.3 x 1.9 x 3.5 cm.  no free fluid is detected.,impression: , single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  a live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  a close interval followup in correlation with beta-hcg is necessary as findings may represent an inevitable abortion.",22
"procedure in detail:  ,while in the holding area, the patient received a peripheral iv from the nursing staff.  in addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  the patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  through the iv, the patient received iv sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% xylocaine plain.  approximately 3 ml were administered.  the patient then underwent a betadine prep with respect to the face, lens, lashes, and eye.  during the draping process, care was taken to isolate the lashes.  a vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  blunt dissection was carried out in the superotemporal quadrant.  next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  this flap was cut forward to clear cornea using a crescent blade.  the ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  the knots were trimmed.  the tube was then cut to an appropriate length to enter the anterior chamber.  the anterior chamber was then entered after a paracentesis wound had been made temporally.  a trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  the tube was sutured in place with a multi-wrapped 8-0 nylon suture.  the scleral flap was then sutured in place with two 10-0 nylon sutures.  the knots were trimmed, rotated and buried.  a scleral patch was then placed of an appropriate size over the two.  it was sutured in place with interrupted 8-0 nylon sutures.  the knots were trimmed.  the overlying conjunctiva was then closed with a running 8-0 vicryl suture with a bv needle.  the anterior chamber was filled with viscoat to keep it deep as the eye was somewhat soft.  a good flow was established with irrigation into the anterior chamber.  homatropine, econopred, and vigamox drops were placed into the eye.  a patch and shield were placed over the eye after removing the draping and the speculum.  the patient tolerated the procedure well.  he was taken to the recovery in good condition.  he will be seen in followup in the office tomorrow.",24
"operation,1.  ivor-lewis esophagogastrectomy.,2.  feeding jejunostomy.,3.  placement of two right-sided #28-french chest tubes.,4.  right thoracotomy.,anesthesia:  ,general endotracheal anesthesia with a dual-lumen tube.,operative procedure in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  in addition, he had a dual-lumen endotracheal tube placed.  the patient was placed in the supine position to begin the procedure.  his abdomen and chest were prepped and draped in the standard surgical fashion.  after applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  dissection was carried down through the linea using bovie electrocautery.  the abdomen was opened.  next, a balfour retractor was positioned as well as a mechanical retractor.  next, our attention was turned to freeing up the stomach.  in an attempt to do so, we identified the right gastroepiploic artery and arcade.  we incised the omentum and retracted it off the stomach and gastroepiploic arcade.  the omentum was divided using suture ligature with 2-0 silk.  we did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  next, we turned our attention to performing a kocher maneuver.  this was done and the stomach was freed up.  we took down the falciform ligament as well as the caudate attachment to the diaphragm.  we enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  we also did a portion of the esophageal dissection from the abdomen into the chest area.  the esophagus and the esophageal hiatus were identified in the abdomen.  we next turned our attention to the left gastric artery.  the left gastric artery was identified at the base of the stomach.  we first took the left gastric vein by ligating and dividing it using 0 silk ties.  the left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  at this point the stomach was freely mobile.  we then turned our attention to performing our jejunostomy feeding tube.  a 2-0 vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of treitz.  we then used bovie electrocautery to open the jejunum at this site.  we placed a 16-french red rubber catheter through this site.  we tied down in place.  we then used 3-0 silk sutures to perform a witzel.  next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  after doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  this was done with #1 prolene.  we put in a 2nd layer of 2-0 vicryl.  the skin was closed with 4-0 monocryl.,next, we turned our attention to performing the thoracic portion of the procedure.  the patient was placed in the left lateral decubitus position.  the right chest was prepped and draped appropriately.  we then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  dissection was carried down to the level of the ribs with bovie electrocautery.  next, the ribs were counted and the 5th interspace was entered.  the lung was deflated.  we placed standard chest retractors.  next, we incised the peritoneum over the esophagus.  we dissected the esophagus to just above the azygos vein.  the azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  as mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  after doing this, we backed our ng tube out to above the level where we planned to perform our pursestring.  we used an automatic pursestring and applied.  we then transected the proximal portion of the stomach with metzenbaum scissors.  we secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  the pursestring was then tied down without difficulty.  next, we tabularized our stomach using a #80 gia stapler.  after doing so, we chose a portion of the stomach more distally and opened it using bovie electrocautery.  we placed our eea stapler through it and then punched out through the gastric wall.  we connected our anvil to the eea stapler.  this was then secured appropriately.  we checked to make sure that there was appropriate muscle apposition.  we then fired the stapler.  we obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  we also sent the gastroesophageal specimen for pathology.  of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  we then turned our attention to closing the gastrostomy opening.  this was closed with 2-0 vicryl in a running fashion.  we then buttressed this with serosal 3-0 vicryl interrupted sutures.  we returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  next, we placed two #28-french chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  we then closed the chest with #2 vicryl in an interrupted figure-of-eight fashion.  the lung was brought up.  we closed the muscle layers with #0 vicryl followed by #0 vicryl; then we closed the subcutaneous layer with 2-0 vicryl and the skin with 4-0 monocryl.  sterile dressing was applied.  the instrument and sponge count was correct at the end of the case.  the patient tolerated the procedure well and was extubated in the operating room and transferred to the icu in good condition.",2
"exam:  ,three views of the right foot.,reason for exam: , right foot trauma.,findings: , three views of the right foot were obtained.  there are no comparison studies.  there is no evidence of fractures or dislocations.  no significant degenerative changes or obstructive osseous lesions were identified.  there are no radiopaque foreign bodies.,impression: , negative right foot.",29
"reason for consult:,  evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,history of present illness: , this is a 50-year-old male who was transferred from sugar land er to abcd hospital for admission to the micu for acute alcohol withdrawal.  the patient had been on a drinking binge for the past 12 days prior to admission and had not been eating.  he reported that he called 911 secondary to noticing bilious vomiting and dry heave.  the patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years.  he has been away from work secondary to alcohol cravings and drinking.  he has also experienced marital and family conflict as a result of his drinking habit.  on average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily.  he reports a history of withdrawal symptoms, but denied history of withdrawal seizures.  his longest period of sobriety was one year, and this was due to the assistance of attending aa meetings.  the patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit.  he reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits.  he denies depressive symptoms.  he denies any psychotic symptoms or perceptual disturbances.  there are no active symptoms of withdrawal at this time.,past psychiatric history: , there are no previous psychiatric hospitalizations or evaluations.  the patient denies any history of suicidal attempts.  there is no history of inpatient rehabilitation programs.  he has attended aa for periodic moments throughout the past few years.  he has been treated with antabuse before.,past medical history:,  the patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,medications: , his outpatient medications include lotrel 30 mg p.o. q.a.m. and restoril 30 mg p.o. q.h.s.,inpatient medications are vitamin supplements, potassium chloride, lovenox 40 mg subcutaneously daily, lactulose 30 ml q.8h., nexium 40 mg iv daily, ativan 1 mg iv p.r.n. q.6-8h.,allergies:,  no known drug allergies.,family history: , distant relatives with alcohol dependance.  no other psychiatric illnesses in the family.,social history:,  the patient has been divorced twice.  he has two daughters one from each marriage, ages 15 and 22.  he works as a geologist at petrogas.  he has limited contact with his children.  he reports that his children's mothers have turned them against him.  he and his wife have experienced marital discord secondary to his alcohol use.  his wife is concerned that he may loose his job because he has skipped work before without reporting to his boss.  there are no other illicit drugs except alcohol that the patient reports.,physical examination:,  vital signs:  temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,mental status examination:,  this is a well-groomed male.  he appears his stated age.  he is lying comfortably in bed.  there are no signs of emotional distress.  he is pleasant and engaging.  there are no psychomotor abnormalities.  no signs of tremulousness.  his speech is with normal rate, volume, and inflection.  mood is reportedly okay.  affect euthymic.  thought content, no suicidal or homicidal ideations.  no delusions.  thought perception, there are no auditory or visual hallucinations.  thought process, logical and goal directed.  insight and judgment are fair.  the patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,laboratory data:,  cbc:  wbc 5.77, h&h 14 and 39.4 respectively, and platelets 102,000.  bmp:  sodium 140, potassium 3, chloride 104, bicarbonate 26, bun 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, pt 13.4, and inr 1.0.  lfts:  alt 64, ast 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2.  pfts within normal limits.,imaging:,  cat scan of the abdomen and pelvis reveals esophagitis and fatty liver.  no splenomegaly.,assessment:,  this is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver.  the patient currently has no signs of withdrawal.  the patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use.  the patient had severe insomnia that is likely secondary to alcohol use.  currently, there are no signs of primary anxiety disorder in this patient.,diagnoses:,  axis i:  alcohol dependence.,axis ii:  deferred.,axis iii:  fatty liver, esophagitis, and hypertension.,axis iv:  marital discord, estranged from children.,axis v:  global assessment of functioning equals 55.,recommendations:,1.  continue to taper off p.r.n. ativan and discontinue all ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient.  discontinue outpatient restoril.  the patient has been informed of the hazards of using benzodiazepines along with alcohol.,2.  continue alcoholics anonymous meetings to maintain abstinence.,3.  recommend starting campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4.  supplement with multivitamin, thiamine, and folate upon discharge and before.  marital counseling strongly advised as well as individual therapy for patient once sobriety is reached.  referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5.  alcohol education and counseling provided during consultation.,6.  trazodone 50 mg p.o. q.h.s. for insomnia.,7.  follow up with pcp in 1 to 2 weeks.",4
"procedure: , endotracheal intubation.,indication: , respiratory failure.,brief history: , the patient is a 52-year-old male with metastatic osteogenic sarcoma.  he was admitted two days ago with small bowel obstruction.  he has been on coumadin for previous pe and currently on heparin drip.  he became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  a code blue was called.  on my arrival, the patient's vital signs are stable.  his blood pressure is systolically in 140s and heart rate 80s.  he however has 0 respiratory effort and is unresponsive to even painful stimuli.  the patient was given etomidate 20 mg.,description of procedure:  ,the patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  mac-4 blade was used.  a 7.5 et tube placed to 24th teeth.  there is good color change on the capnographer with bilateral breath sounds.  following intubation, the patient's blood pressure began to drop.  he was given 2 l of bolus.  i started him on dopamine drip at 10 mcg.  dr. x was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the icu.  chest x-ray will be reviewed and pulmonary will be consulted.",2
"cc: ,gait difficulty.,hx: ,this 59 y/o rhf was admitted with complaint of gait difficulty. the evening prior to admission she noted sudden onset of lue and lle weakness. she felt she favored her right leg, but did not fall when walking. she denied any associated dysarthria, facial weakness, chest pain, sob, visual change, ha, nausea or vomiting.,pmh:, tonsillectomy, adenoidectomy, skull fx 1954, htn, ha.,meds: ,none on day of exam.,shx: ,editorial assistant at newspaper, 40pk-yr tobacco, no etoh/drugs.,fhx: ,noncontributory,admit exam: ,p95 r20, t36.6, bp169/104,ms: a&o to person, place and time. speech fluent and without dysarthria, naming-comprehension-reading intact. euthymic with appropriate affect.,cn: pupils 4/4 decreasing to 2/2 on exposure to light, fundi flat, vfftc, eomi, face symmetric with intact sensation, gag-shrug-corneal reflexes intact, tongue ml with full rom,motor: full strength throughout right side. mildly decreased left grip and left extensor hallucis longus. biceps/triceps/wrist flexors and extensor were full strength on left. however she demonstrated mild lue pronator drift and had difficulty standing on her lle despite full strength on bench testing of the lle.,sensory: no deficit to pp/t/vib/prop/ lt,coord: decreased speed and magnitude of fnf, finger tapping and hks, on left side only.,station: mild lue upward drift.,gait: tendency to drift toward the left. difficulty standing on lle.,reflexes were symmetric, plantar responses were flexor bilaterally.,gen exam unremarkable.,course: ,admit labs: esr, pt/ptt, gs, ua, ekg, and hct were unremarkable. hgb 13.9, hct 41%, plt 280k, wbc 5.5.,the patient was diagnosed with a probable lacunar stroke and entered into the toast study (trial of org10172[a low molecular weight heparin] in acute stroke treatment).,carotid duplex: 16-49%rica and 0-15%lica stenosis with anterograde vertebral artery flow, bilaterally. transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. there was no evidence of blood clot.,hospital course: 5 days after admission the patient began to complain of proximal lle and left flank pain. on exam, she had weakness of the quadriceps and hip flexors of the lle. her pain increased with left hip flexion. in addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased pp/temp sensation in a left femoral nerve distribution. she denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,abdominal ct scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,hgb 8.9g/dl. she was transfused with 4 units of prbcs. she underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. her postoperative course was uncomplicated. she was discharged home on asa.,at follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the lle than in the lue) and feeling of ""swollen left foot."" these symptoms had developed approximately 1 month after her stroke. her foot looked normal and her ue strength was 5/4+ proximally and distally, and le strength 5/4+ proximally and 5/5- distally. she was ambulatory. there was no evidence of lue upward drift. a somatosensory evoked potential study revealed an absent n20 and normal p14 potentials. this was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a dejerine-roussy syndrome.",4
"reason for exam:,1.  angina.,2.  coronary artery disease.,interpretation:  ,this is a technically acceptable study.,dimensions:  ,anterior septal wall 1.2, posterior wall 1.2, left ventricular end diastolic 6.0, end systolic 4.7.  the left atrium is 3.9.,findings:  ,  left atrium was mildly to moderately dilated.  no masses or thrombi were seen.  the left ventricle was mildly dilated with mainly global hypokinesis, more prominent in the inferior septum and inferoposterior wall.  the ef was moderately reduced with estimated ef of 40% with near normal thickening.  the right atrium was mildly dilated.  the right ventricle was normal in size.,mitral valve showed to be structurally normal with no prolapse or vegetation.  there was mild mitral regurgitation on color flow interrogation.  the mitral inflow pattern was consistent with pseudonormalization or grade 2 diastolic dysfunction.  the aortic valve appeared to be structurally normal.  normal peak velocity.  no significant ai.  pulmonic valve showed mild pi.  tricuspid valve showed mild tricuspid regurgitation.  based on which, the right ventricular systolic pressure was estimated to be mildly elevated at 40 to 45 mmhg.  anterior septum appeared to be intact.  no pericardial effusion was seen.,conclusion:,1.  mild biatrial enlargement.,2.  normal thickening of the left ventricle with mildly dilated ventricle and ef of 40%.,3.  mild mitral regurgitation.,4.  diastolic dysfunction grade 2.,5.  mild pulmonary hypertension.",2
"postoperative diagnosis: , type 4 thoracoabdominal aneurysm.,operation/procedure: , a 26-mm dacron graft replacement of type 4 thoracoabdominal aneurysm from t10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,description of procedure in detail: , patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  the left groin, abdominal and chest were prepped and draped in a sterile fashion.  a thoracoabdominal incision was made.  the 8th interspace was entered.  the costal margin was divided.  the retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  the inferior pulmonary ligament was then taken down so the aorta could be dissected free at the t10 level just above the diaphragm.  it was dissected free circumferentially.  the aortic bifurcation was dissected free, dissecting free both iliac arteries.  the left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 prolene was placed on this.  the patient was heparinized.  through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a rumel tourniquet.  this was hooked to a venous inflow of left heart bypass machine.  a pursestring of 4-0 prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  bypass was instituted.  the aneurysm was cross clamped just above t10 and also, cross clamped just below the diaphragm.  the area was divided at this point.  a 26-mm graft was then sutured in place with running 3-0 prolene suture.  the graft was brought into the diaphragm.  clamps were then placed on the iliacs, and the pump was shut off.  the aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  the sma, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete carrell patch.  the island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 prolene suture with pledgetted 4-0 prolene sutures around the circumference.  the clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  the graft was cut to fit the bifurcation and sutured in place with running 3-0 prolene suture.  all clamps were removed, and flow was re-established.  an 8-mm graft was sutured end-to-end to the carrell patch and to the left renal.  a partial-occlusion clamp was placed.  an area of graft was removed.  the end of the graft was cut to fit this and sutured in place with running prolene suture.  the partial-occlusion clamp was removed.  protamine was given.  good hemostasis was noted.  the arterial cannula, of course, had been removed when that part of the aneurysm was removed.  the venous cannula was removed and oversewn with a 4-0 prolene suture.  good hemostasis was noted.  a 36 french posterior and a 32 french anterior chest tube were placed.  the ribs were closed with figure-of-eight #2 vicryl.  the fascial layer was closed with running #1 prolene, subcu with running 2-0 dexon and the skin with running 4-0 dexon subcuticular stitch.  patient tolerated the procedure well.",36
"s -, a 60-year-old female presents today for care of painful calluses and benign lesions.,o -, on examination, the patient has bilateral bunions at the first metatarsophalangeal joint.  she states that they do not hurt.  no pain appears to be produced by active or passive range of motion or palpation and direct pressure of the first metatarsophalangeal joint bilaterally.  the patient has a bilateral pinch callus on the medial aspect of both great toes and there are calluses along the medial aspect of the right foot.  she has a small intractable plantar keratoma, plantar to her left second metatarsal head, which measures 0.5 cm in diameter.  this is a central plug.  she also has a very, very painful lesion plantar to her right fourth metatarsal head which measures 3.1 x 1.8 cm in diameter.  this is a hyperkeratotic lesion that extends deep into the tissue with interrupted skin lines.,a - ,1.  bilateral bunions.,",29
"reason for visit:,  this is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation.  her chief complaint today is shortness of breath.,history of present illness:,  i last saw her in 09/2008.  since then, she has been admitted to abcd hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode.  she was found to have a fast heart rate in the atrial fibrillation.  she was also found to be in heart failure and so they diuresed her.  they wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise.  my plan advent is to control her heart rate.  this has been a bit difficult with her retaining fluid.  we will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation.  she may need to have a pacemaker placed and her av node ablated if this does not work.,she notes the shortness of breath and wheezing at nights.  i think these are manifestations of heart failure.  she has peripheral edema.  she is short of breath when she tries to walk a city block.  i believe she takes her medications as directed, but i am never sure she actually is taking them correctly.  in any case, she did not bring her medications with her today.,today, she had an ecg which shows atrial fibrillation with a ventricular response of 117 beats per minute.  there is a nonspecific ivcd.  this is unchanged from her last visit except that her heart rate is faster.  in addition, i reviewed her echocardiogram done at xyz.  her ejection fraction is 50% and she has paradoxical septal motion.  her right ventricular systolic pressure is normal.  there are no significant valvular abnormalities.,medications:  ,1.  fosamax - 70 mg weekly.,2.  lisinopril - 20 mg daily.,3.  metformin - 850 mg daily.,4.  amlodipine - 5 mg daily.,5.  metoprolol - 150 mg twice daily.,6.  warfarin - 5 mg daily.,7.  furosemide - none.,8.  potassium - none.,9.  magnesium oxide - 200 mg daily.,allergies: , denied.,major findings:,  on my comprehensive cardiovascular examination, she again looks the same which is in heart failure.  her blood pressure today was 130/60 and her pulse 116 blood pressure and regular.  she is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when i saw her last visit.  she is breathing 1two times per minute and it is unlabored.  eyelids are normal.  she has vitiligo.  pupils are round and reactive to light.  conjunctivae are clear and sclerae are anicteric.  there is no oral thrush or central cyanosis.  she has marked keloid formation on both sides of her neck, the left being worse than the right.  the jugular venous pressure is elevated.  carotids are brisk are without bruits.  lungs are clear to auscultation and percussion.  the precordium is quiet.  the rhythm is irregularly irregular.  she has a variable first and second heart sounds.  no murmurs today.  abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux.  she has no clubbing or cyanosis, but does have 1+ peripheral edema.  distal pulses are good.  on neurological examination, her mentation is normal.  her mood and affect are normal.  she is oriented to person, place, and time.,assessments: , she has chronic atrial fibrillation and heart failure now.,problems diagnoses:  ,1.  chronic atrial fibrillation, anticoagulated and the plan is rate control.,2.  heart failure and she needs more diuretic.,3.  high blood pressure controlled.,4.  hyperlipidemia.,5.  diabetes mellitus type 2.,6.  nonspecific intraventricular conduction delay.,7.  history of alcohol abuse.,8.  osteoporosis.,9.  normal left ventricular function.,procedures and immunizations: , none today.,plans: , i have restarted her lasix at 80 mg daily and i have asked her to return in about 10 days to the heart failure clinic.  there, i would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily.  if this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her av node ablated.,thank you for asking me to participate in her care.,medication changes: , see the above.",4
"preoperative diagnosis:  ,1.  left carpal tunnel syndrome.,2.  de quervain's tenosynovitis.,postoperative diagnosis:,  ,1.  left carpal tunnel syndrome.,2.  de quervain's tenosynovitis.,operations performed:  ,1.  endoscopic carpal tunnel release.,2.  de quervain's release.,anesthesia:,  i.v. sedation and local (1% lidocaine).,estimated blood loss:,  zero.,complications:,  none.,procedure in detail:  ,endoscopic carpal tunnel release:,  with the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  the arm was exsanguinated.  the tourniquet was elevated at 290 mm/hg.  construction lines were made on the left palm to identify the ring ray.  a transverse incision was made in the wrist, between fcr and fcu, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  blunt dissection exposed the antebrachial fascia.  hemostasis was obtained with bipolar cautery.  a distal-based window in the antebrachial fascia was then fashioned.  care was taken to protect the underlying contents.  a proximal forearm fasciotomy was performed under direct vision.  a synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  hamate sounds were then used to palpate the hook of hamate.  the endoscopic instrument was then inserted into the proximal incision.  the transverse carpal ligament was easily visualized through the portal.  using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,the distal end of the transverse carpal ligament was then identified in the window.  the blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  after complete division o the transverse carpal ligament, the instrument was reinserted.  radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,the wound was then closed with running subcuticular stitch.  steri-strips were applied, and sterile dressing was applied over the steri-strips.  the tourniquet was deflated.  the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition, having tolerated the procedure well.,de quervain's release: , with the patient under adequate regional anesthesia applied by surgeon using 1% plain xylocaine, the upper extremity was prepped and draped in a sterile manner.  the arm was exsanguinated.  the tourniquet was elevated to 290 mm/hg.  a transverse incision was then made over the radial aspect of the wrist overlying the first dorsal tunnel.  using blunt dissection, the radial sensory nerve branches were dissected and retracted out of the operative field.  the first dorsal tunnel was then identified.  the first dorsal tunnel was incised along the dorsal ulnar border, completely freeing the stenosing tenosynovitis (de quervain's release).  epb and apl tendons were inspected and found to be completely free.  the radial sensory nerve was inspected and found to be without damage.,the skin was closed with a running 3-0 prolene subcuticular stitch and steri-strips were applied and, over the steri-strips, a sterile dressing, and, over the sterile dressing, a volar splint with the hand in safe position.  the tourniquet was deflated.  the patient was returned to the holding area in satisfactory condition, having tolerated the procedure well.",36
"preoperative diagnosis: , left medial compartment osteoarthritis of the knee.,postoperative diagnosis:,  left medial compartment osteoarthritis of the knee.,procedure  performed:,  left unicompartmental knee replacement.,components used:,  biomet size medium femoral component size b tibial tray and a 3 mm polyethylene component.,complications:,  none.,tourniquet time: , 59 minutes.,blood loss: , minimal.,indications for procedure: , a 55-year-old female who had previously undergone a biomet oxford unicompartmental knee replacement on the right side.  she has done quite well with this.  she now has had worsening left knee pain predominantly on the inside of her knee and has consented for unicompartmental knee replacement on the left.,description of procedure in detail: , the patient was brought to the operating room and placed supine on the operating room table.  after appropriate anesthesia, the left lower extremity was identified with a time out procedure.  preoperative antibiotics were given.  left lower extremity was then prepped and draped in usual sterile fashion after applying a thigh tourniquet.  the tourniquet was insufflated after elevation of the limb, and a standard medial parapatellar incision was used.  soft tissue dissection was carried down the retinaculum, was opened sharply to expose the joint, meniscus that was visible along the tibia was removed.  the anterior fat pad was removed.  the knee was then examined.  the acl was found to be intact.  the lateral compartment had very minimal arthritis.  there were some osteoarthritic changes of the patellofemoral joint, but these were felt to be mild.  following this, the tibial external alignment guide was placed and pinned into place in the appropriate place.  tibial bone cut was made and checked with a feeler gauge and felt to be an adequate resection.  following this resection, the femoral intramedullary guide was placed without difficulty.  the femoral cutting guide was then placed and referenced off of this femoral intramedullary guide.  once in the appropriate position, it was pinned and drilled.  this was removed, and the posterior cutting block was inserted.  it was impacted into place.  posterior bone cut was made for the medium femoral component.  next, a zero spigot was used and the distal femur was reamed.  following this, the check of the extension and flexion gaps revealed that an additional 1 mm needed to be reamed, so 1 spigot was used and this was reamed as well.  next, trial components were placed into the knee and the knee was taken through range of motion and felt to come out to full extension with a 3 mm poly with a good fit.  next, the tibia was prepared.  the tibial tray was pinned into place, and the cuts for the keel of the tibia were made.  these were removed with a small osteotome from the set.  following this, a trial tibial with the keel was placed and it did fit nicely.  after this, all trial components were removed.  the knee was copiously irrigated.  cement was begun mixing.  drill holes were used along the femur for cement interdigitation.  the wound was cleaned and dried.  cement was placed on the tibia.  tibial tray was impacted into place.  excess cement was removed.  tibia was placed in the femur.  femoral component was impacted into place.  excess cement was removed.  it was held with a 4 mm trial insert and approximately 30 degrees of knee flexion until the cement had hardened.  following this, it was again trialed with a meniscal bearing implant and it was felt that 3 mm would be the appropriate size.  a 3 mm polyethylene was chosen and inserted in the knee without difficulty, taken through range of motion and found to come out to full extension with no impingement and full flexion.  the intramedullary rod removed from the femur.  the wound was irrigated with normal saline.  the retinaculum was closed with #1 pds, 2-0 monocryl was used for the subcutaneous tissue and staples used for the skin.  a sterile dressing was placed.  tourniquet was then desufflated.  sponge and needle counts were correct at the end of the procedure.  dr. jinnah was present for the surgery.  the patient was transferred to the recovery room in stable condition.  she will be weightbearing as tolerated in the left lower extremity and will be maintained on lovenox for dvt prophylaxis.  prior to closure, the posterior capsule was injected with the joint cocktail.",25
"preoperative diagnosis: , syncopal episodes with injury.  see electrophysiology consultation.,postoperative diagnoses:,1.  normal electrophysiologic studies.,2.  no inducible arrhythmia.,3.  procainamide infusion negative for brugada syndrome.,procedures:,1.  comprehensive electrophysiology studies with attempted arrhythmia induction.,2.  iv procainamide infusion for brugada syndrome.,description of procedure:, the patient gave informed consent for comprehensive electrophysiologic studies.  she received small amounts of intravenous fentanyl and versed for conscious sedation.  then 1% lidocaine local anesthesia was used.  three catheters were placed via the right femoral vein; 5-french catheters to the right ventricular apex and right atrial appendage; and a 6-french catheter to the his bundle.  later in the procedure, the rv apical catheter was moved to rv outflow tract.,electrophysiological findings:,  conduction intervals in sinus rhythm were normal.  sinus cycle length 768 ms, pa interval 24 ms, ah interval 150 ms, hv interval 46 ms.  sinus node recovery times were also normal at 1114 ms.  corrected sinus node recovery time was normal at 330 ms.  one-to-one av conduction was present to cycle length 480 ms, ah interval 240 ms, hv interval 54 ms.  av nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms.  ra-erp was 250 ms.  with ventricular pacing, there was va disassociation present.,since there was no evidence for dual av nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for svt.,programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts.  drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness.  there was no inducible vt.  longest run was 5 beats of polymorphic vt, which is a nonspecific finding.  from the apex 400-600 with 2 extrastimuli were delivered, again with no inducible vt.,procainamide was then infused, 20 mg/kg over 10 minutes.  there were no st segment changes.  hv interval after iv procainamide remained normal at 50 ms.,assessment: , normal electrophysiologic studies.  no evidence for sinus node dysfunction or atrioventricular block.  no inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for brugada syndrome.,plan: , the patient will follow up with dr. x.  she recently had an ambulatory eeg.  i will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes.  reveal event monitor was considered, but not placed since she has only had one single episode.",31
"preoperative diagnoses: , colon cancer screening and family history of polyps.,postoperative diagnosis:,  colonic polyps.,procedure:,  colonoscopy.,anesthesia:,  mac,description of procedure:  ,the olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  the preparation was excellent and all surfaces were well seen.  the mucosa was normal throughout the colon and in the terminal ileum.  two polyps were identified and were removed.  the first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  the second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  no other lesions were identified.  numerous diverticula were found in the sigmoid colon.  a retroflex through the anorectal junction showed moderate internal hemorrhoids.  the patient tolerated the procedure well and was sent to the recovery room.,final diagnoses:,1.  sigmoid diverticulosis.,2.  colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  internal hemorrhoids.,4.  otherwise normal colonoscopy to the terminal ileum.,recommendations:,1.  follow up biopsy report.,2.  follow up with dr. x as needed.,3.  screening colonoscopy in 5 years.",36
"preoperative diagnosis: , empyema of the chest, left.,postoperative diagnosis: , empyema of the chest, left.,procedure: , left thoracotomy with total pulmonary decortication and parietal pleurectomy.,procedure detail: , after obtaining the informed consent, the patient was brought to the operating room, where he underwent a general endotracheal anesthetic using a double-lumen endotracheal tube.  a time-out process had been followed and preoperative antibiotics were given.,the patient was positioned with the left side up for a left thoracotomy.  the patient was prepped and draped in the usual fashion.  a posterolateral thoracotomy was performed.  it included the previous incision.  the chest was entered through the fifth intercostal space.  actually, there was a very strong and hard parietal pleura, which initially did not allow us to obtain a good exposure, and actually the layer was so tough that the pin of the chest retractor broke.  thanks to dr. x's ingenuity, we were able to reuse the chest retractor and opened the chest after i incised the thickened parietal pleura resulting in an explosion of gas and pus from a cavity that was obviously welled off by the parietal pleura.  we aspirated an abundant amount of pus from this cavity.  the sample was taken for culture and sensitivity.,then, at least half an hour was spent trying to excise the parietal pleura and finally we were able to accomplish that up to the apex and back to the aorta __________ towards the heart including his diaphragm.  once we accomplished that, we proceeded to remove the solid exudate that was adhered to the lung.  further samples for culture and sensitivity were sent.,then, we were left with the trapped lung.  it was trapped by thickened visceral pleura.  this was the most difficult part of the operation and it was very difficult to remove the parietal pleura without injuring the lung extensively.  finally, we were able to achieve this and after the corresponding lumen of the endotracheal tube was opened, we were able to inflate both the left upper and lower lobes of the lung satisfactorily.  there was only one area towards the mediastinum that apparently i was not able to fill.  this area, of course, was very rigid but any surgery in the direction __________ would have caused __________ injury, so i restrained from doing that.  two large chest tubes were placed.  the cavity had been abundantly irrigated with warm saline.  then, the thoracotomy was closed in layers using heavy stitches of vicryl as pericostal sutures and then several figure-of-eight interrupted sutures to the muscle layers and a combination of nylon stitches and staples to the skin.,the chest tubes were affixed to the skin with heavy sutures of silk.  dressings were applied and the patient was put back in the supine position and after a few minutes of observation and evaluation, he was able to be extubated in the operating room.,estimated blood loss was about 500 ml.  the patient tolerated the procedure very well and was sent to the icu in a satisfactory condition.",2
"subjective:,  mr. sample patient returns to the sample clinic with the chief complaint of painful right heel.  the patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  the patient states that he is currently doing no treatment for it.  he states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  the patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,objective:,  upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  there is tenderness to palpation to the medial tubercle of the right foot.  the pain is elicited along the medial arch as well.  there are no open areas or signs of infection noted.,assessment:,  plantar fascitis/heel spur syndrome, right foot.,plan:,  the patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  he was given a low dye strapping and a heel lift was placed in his right shoe.  the patient will be seen back in approximately one month for further evaluation if necessary.  he was told to call if anything should occur before that.  the patient was told to continue with the good work on his diabetic control.",33
"chief complaint:,  abdominal pain.,history of present illness:,  the patient is a 71-year-old female patient of dr. x. the patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  she was seen 3 to 4 days ago at abc er and underwent evaluation and discharged and had a ct scan at that time and she was told it was ""normal.""  she was given oral antibiotics of cipro and flagyl.  she has had no nausea and vomiting, but has had persistent associated anorexia.  she is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  she denies any bright red blood per rectum and no history of recent melena.  her last colonoscopy was approximately 5 years ago with dr. y. she has had no definite fevers or chills and no history of jaundice.  the patient denies any significant recent weight loss.,past medical history:  ,significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on premarin hormone replacement.,past surgical history: , significant for cholecystectomy, appendectomy, and hysterectomy.  she has a long history of known grade 4 bladder prolapse and she has been seen in the past by dr. chip winkel, i believe that he has not been re-consulted.,allergies: , she is allergic or sensitive to macrodantin.,social history: , she does not drink or smoke.,review of systems: , otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,physical examination:,general:  the patient is an elderly thin white female, very pleasant, in no acute distress.,vital signs:  her temperature is 98.8 and vital signs are all stable, within normal limits.,heent:  head is grossly atraumatic and normocephalic.  sclerae are anicteric.  the conjunctivae are non-injected.,neck:  supple.,chest:  clear.,heart:  regular rate and rhythm.,abdomen:  generally nondistended and soft.  she is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  there is no cva or flank tenderness, although some very minimal left flank tenderness.,pelvic:  currently deferred, but has history of grade 4 urinary bladder prolapse.,extremities:  grossly and neurovascularly intact.,laboratory values:  ,white blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  alkaline phosphatase elevated at 184.  liver function tests otherwise normal.  electrolytes normal.  glucose 134, bun 4, and creatinine 0.7.,diagnostic studies:,  ekg shows normal sinus rhythm.,impression and plan: , a 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  currently is a nonacute abdomen.  the working diagnosis would be sigmoid diverticulitis.  she does have a history in the distant past of sigmoid diverticulitis.  i would recommend a repeat stat ct scan of the abdomen and pelvis and keep the patient nothing by mouth.  the patient was seen 5 years ago by dr. y in colorectal surgery.  we will consult her also for evaluation.  the patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  the case was discussed with the patient's primary care physician, dr. x. again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.",13
"preoperative diagnosis:,  acute appendicitis.,postoperative diagnosis: , acute appendicitis, gangrenous.,procedure: , appendectomy.,description of procedure: , the patient was taken to the operating room under urgent conditions.  after having obtained an informed consent, he was placed in the operating room and under anesthesia.  followed by a time-out process, his abdominal wall was prepped and draped in the usual fashion.  antibiotics had been given prior to incision.  a mcburney incision was performed and it carried out through the peritoneal cavity.  immediately there was  purulent material seen in the area.  samples were taken for culture and sensitivity of aerobic and anaerobic sets.  the appendix was markedly swollen particularly in its distal three-fourth, where the distal appendix showed an abscess formation and devitalization of the wall.  there was quite a bit of local peritonitis.  the mesoappendix was clamped, divided and ligated, and then the appendix was ligated and divided, and the stump buried with a pursestring suture of vicryl and then a z stitch.  the area was abundantly irrigated with normal saline and also the pelvis.  the distal foot of small bowel had been explored and because it delivered itself __________ the incision and showed no pathology.,then the peritoneal and internal fascia were approximated with a suture of 0 vicryl and then the incision was closed in layers and after each layer the wound was irrigated with normal saline.  the skin was closed with a combination of a subcuticular suture of fine monocryl followed by the application of dermabond.  the patient tolerated the procedure well.  estimated blood loss was minimal, and the patient was sent to the recovery room for recovery in satisfactory condition.,",36
"procedure:,  carpal tunnel release with transverse carpal ligament reconstruction.,procedure in detail: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,a longitudinal incision was made in line with the fourth ray, from kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  the dissection was carried down to the superficial aponeurosis.  the subcutaneous fat was dissected radially for 2-3 mm, and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,the ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  the hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  the antebrachial fascia was cut proximally under direct vision with a scissor.,after irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 vicryl.  care was taken to avoid entrapping the motor branch of the median nerve in the suture.  a hemostat was placed under the repair to ensure that the median nerve was not compressed.  the skin was repaired with 5-0 nylon interrupted stitches.,marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  the patient was sent to the recovery room in good condition, having tolerated the procedure well.",25
"preoperative diagnosis: , bilateral knee degenerative arthritis.,postoperative diagnosis: , bilateral knee degenerative arthritis.,procedure performed: , bilateral knee arthroplasty.,please note this procedure was done by dr. x for the left total knee and dr. y for the right total knee.  this operative note will discuss the right total knee arthroplasty.,anesthesia:  ,general.,complications: , none.,blood loss: , approximately 150 cc.,history:,  this is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  she has been unresponsive to conservative measures.  all risks, complications, anticipated benefits, and postoperative course were discussed.  the patient has agreed to proceed with surgery as described below.,gross findings: , there was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,specifications: , the zimmer nexgen total knee system was utilized.,procedure: , the patient was taken to the operating room #2 and placed in supine position on the operating room table.  she was administered spinal anesthetic by dr. z.,the tourniquet was placed about the proximal aspect of the right lower extremity.  the right lower extremity was then sterilely prepped and draped in the usual fashion.  an esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmhg.  longitudinal incision was made over the anterior aspect of the right knee.  subcutaneous tissue was carefully dissected.  a medial parapatellar retinacular incision was made.  the patella was then everted and the above noted gross findings were appreciated.  a drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  the appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  the trial femoral component was then positioned in place and noted to have good fit.  attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  the medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  the remnants of the anterior cruciate ligament and menisci were resected.  the tibial trial was positioned in place.  intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  the tibial holes were then drilled.  the patella was then addressed with the bovie used to remove the soft tissue around the perimeter of the patella.  the patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  the knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  the tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  the femoral component was inserted with methylmethacrylate.  any excessive methylmethacrylate and bony debris were removed from the joint.  trial poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  the methylmethacrylate was also used at the patella.  the prosthesis was positioned in place.  the patellar clamp held securely till the methylmethacrylate was firm.  after all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  this component was removed and revised to a stemmed component with better alignment and position.  the previous component removed, the methylmethacrylate was removed.  further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  the trial tibial stemmed component was positioned in place.  knee was placed through range of motion and the tracking was better.  actual component was then obtained, methyl methacrylate was placed within the tibia.  the stemmed tibial component was impacted into place with good fit.  the poly was then positioned in place.  knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  the trial poly was removed.  wound was irrigated and the joint was inspected.  there was no debris.  collateral ligaments and posterior cruciate ligaments remained intact.  soft tissue balancing was done and a 17 mm poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  the tourniquet was deflated.  hemostasis was satisfactory.  a drain was placed into the depths of the wound.  the medial retinacular incision was closed with one ethibond suture in interrupted fashion.  the knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  the subcutaneous tissue was closed with #2-0 undyed vicryl in interrupted fashion.  the skin was closed with surgical clips.  the exterior of the wound was cleansed as well padded dressing abds and ace wrap over the right lower extremity.  at the completion of the procedure, distal pulses were intact.  toes were pink, warm, with good capillary refill.  distal neurovascular status was intact.  postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  prognosis is good in this 79-year-old female with a significant degenerative arthritis.",36
"procedure:,  total hip replacement.,procedure description:,  the patient was bought to the operating room and placed in the supine position.  after induction of anesthesia, the patient was turned on the side and secured in the hip table.  an incision was made, centered over the greater trochanter.  dissection was sharply carried down through the subcutaneous tissues.  the gluteus maximus was incised and split proximally.  the piriformis and external rotators were identified.  these were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  the hip was dislocated.  a femoral neck cut was made using the guidance of preoperative templating.  the femoral head was removed.  extensive degenerative disease was found on the femoral head as well as in the acetabulum.,baseline leg-length measurements were taken.  the femur was retracted anteriorly and a complete labrectomy was performed.  reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  the trial shell was placed and found to have an excellent fit.  the real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  excellent purchase was obtained.  the trial liner was placed.,the femur was then flexed and internally rotated.  the extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  an intramedullary hole was drilled into the femur to define the canal.  reaming was performed until the appropriate size was reached.  the broaches were then used to prepare the femur with the appropriate amount of version.  once the appropriate size broach was reached, it was used as a trial with head and neck placement.  hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  the hip was found to have excellent stability with the final chosen head-neck combination.  leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,the real stem was opened and impacted into position.  the real head was impacted atop the stem.  if cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  excess cement was removed from the edges of the component.  range of motion and stability were once again checked and found to be excellent.  adequate hemostasis was obtained.  vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,the arthrotomy and rotators were closed using #1 ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  the gluteus maximus was repaired using 0 ethibond and 0 vicryl.  the subcutaneous tissues were closed after further irrigation with 2-0 vicryl and monocryl sutures.  the skin was closed with nylon.  xeroform and a sterile dressing were applied followed by a cold pack and ace wrap.  the patient was transferred to the recovery room in stable condition, having tolerated the procedure well.",25
"reason for consultation: , new-onset seizure.,history of present illness: , the patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  the typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  there have been no recent changes in her keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,past medical history: , born at 36 weeks' gestation by c-section delivery at 8 pounds 3 ounces.  she does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,past surgical history: , she has undergone no surgical procedures.,family medical history: , there is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  there is no other significant neurological history on the paternal side of the family.,social history: , currently lives with her mom, dad, and two siblings.  she is at home full time and does not attend day care.,review of systems:  ,clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,physical examination:,vital signs:  weight was 15.6 kg.  she was afebrile.  remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,general:  she was awake, alert, and oriented.  she was in no acute distress, only slightly flustered when trying to place the eeg leads.,heent:  showed normocephalic and atraumatic head.  her conjunctivae were nonicteric and sclerae were clear.  her eye movements were conjugate in nature.  her tongue and mucous membranes were moist.,neck:  trachea appeared to be in the midline.,chest:  clear to auscultation bilaterally without crackles, wheezes or rhonchi.,cardiovascular:  showed a normal sinus rhythm without murmur.,abdomen:  showed soft, nontender, and nondistended, with good bowel sounds.  there was no hepatomegaly or splenomegaly, or other masses noted on examination.,extremities:  showed iv placement in the right upper extremity with appropriate restraints from the iv.  there was no evidence of clubbing, cyanosis or edema throughout.  she had no functional deformities in any of her peripheral limbs.,neurological:  from neurological standpoint, her cranial nerves were grossly intact throughout.  her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  her overall resting tone was normal.  sensory examination was grossly intact to light touch throughout the upper and lower extremities.  reflexes were 1+ in bilateral patella.  toes were downgoing bilaterally.  coordination showed accurate striking ability and good rapid alternating movements.  gait examination was deferred at this time due to eeg lead placement.,assessment:,  a 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,recommendations,1.  for now, we will go ahead and try to capture eeg as long as she tolerates it; however, if she would require sedation, i would defer the eeg until further adjustments to seizure medications are made and we will see her response to these medications.,2.  as per the above, i will increase her keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  if further spells are noted, we may increase upwards again to around 4.5 to 5 ml each day.,3.  i do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her eeg findings.  eeg, hopefully, will be able to be reviewed first thing tomorrow morning; however, i would not delay discharge the patient to wait on the eeg results.  the patient has been discharged and we will contact the family as an outpatient.,4.  the patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.",20
"preoperative diagnoses,1.  left neck pain with left upper extremity radiculopathy.,2.  left c6-c7 neuroforaminal stenosis secondary to osteophyte.,postoperative diagnoses,1.  left neck pain with left upper extremity radiculopathy.,2.  left c6-c7 neuroforaminal stenosis secondary to osteophyte.,operative procedure,1.  anterior cervical discectomy with decompression c6-c7.,2.  arthrodesis with anterior interbody fusion c6-c7.,3.  spinal instrumentation using pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  peek implant 7 mm.,5.  allograft using vitoss.,anesthesia: , general endotracheal anesthesia.,findings: , showed osteophyte with a disc complex on the left c6-c7 neural foramen.,fluids:  ,1800 ml of crystalloids.,urine output: , no foley catheter.,drains:  ,round french 10 jp drain.,specimens,:  none.,complications: , none.,estimated blood loss:,  250 ml.,the need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,condition: , extubated with stable vital signs.,indications for the operation:,  this is the case of a very pleasant 46-year-old caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  the patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  this resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  she was seen in clinic on 12/11/07 during which time mri of the left shoulder showed no evidence of rotator cuff tear.  she did have a previous mri of the cervical spine that did show an osteophyte on the left c6-c7 level.  based on this, negative mri of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at c6-c7 level.  operation, expected outcome, risks, and benefits were discussed with her.  risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  there is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  there is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  however, the patient may develop deeper-seated infection, which may require return to the operating room.  should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  there is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  there is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  there is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  there is also the risk of pseudoarthrosis and hardware failure.  she understood all of these risks and agreed to have the procedure performed.,description of procedure: , the patient brought to the operating room, awake, alert, not in any form of distress.  after smooth induction and intubation, a foley catheter was inserted.  monitoring leads were placed by premier neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  the emgs were silent and there was no evidence of any stimulation.  after completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  the head was supported on a foam doughnut.  the right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  a linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  the area was then prepped with duraprep.,after sterile drapes were laid out, the incision was made using a scalpel blade #10.  wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  the anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  the prevertebral fascia was identified and cut sharply.  a localizing x-ray verified the marker to be at the c6-c7 interspace.  proceeded to the strip the longus colli muscles off the vertebral body of c6 and c7.  self-retaining retractor was then laid out.  the annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  the interior endplate of c6 and superior endplate of c7 was likewise was drilled down together with posteroinferior edge of c6 and the posterior superior edge of c7.  there was note of a new osteophyte on the left c6-c7 foramen.  this was carefully drilled down.  after decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  they were controlled with slight bipolar coagulation, temporary tamponade with gelfoam.  after this was completed, valsalva maneuver showed no evidence of any csf leakage.  a 7-mm implant was then tapped into placed after its interior was packed with vitoss.  the plate was then applied and secured in place with four 12 x 4.7 mm screws.  irrigation of the area was done.  a round french 10 jp drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures as well as vicryl 4-0 subcuticular stitch for the dermis.  the wound was reinforced with dermabond.  the catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  c-collar was placed and the patient was transferred to recovery after extubation.",25
"preoperative diagnosis:,  chronic tonsillitis.,postoperative diagnosis: , chronic tonsillitis.,procedure:  ,tonsillectomy.,description of procedure: , under general orotracheal anesthesia, a crowe-davis mouth gag was inserted and suspended.  tonsils were removed by electrocautery dissection and the tonsillar beds were injected with marcaine 0.25% plain.  a catheter was inserted in the nose and brought out from mouth.  the throat was irrigated with saline.  there was no further bleeding.  the patient was awakened and extubated and moved to the recovery room in satisfactory condition.",10
"preoperative diagnosis:,  t11 compression fracture with intractable pain.,postoperative diagnosis:,  t11 compression fracture with intractable pain.,operation performed:,  unilateral transpedicular t11 vertebroplasty.,anesthesia:,  local with 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.  using ap and lateral fluoroscopic projections the t11 compression fracture was identified.  starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the t11 pedicle on the left.  the 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle.  at this point using ap and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times.  once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body.  at this point polymethylmethacrylate was mixed for 60 seconds.  once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body.  it was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra.  a total 1.2 cc of cement was injected.  on lateral view, the cement crushed to the right side as well.  there was some dye infiltration into the disk space.  there was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,at this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space.  once the needle was withdrawn safely pressure was held over the site for three minutes.  there were no complications.  the patient was taken back to the recovery area in stable condition and kept flat for one hour.  should be followed up the next morning.",36
"history: , smoking history 50-pack years of smoking.,indication: , dyspnea.,procedure: , fvc was 59%.  fev1 was 45%.  fev1/fvc ratio was 52%. the predicted was 67%.  fef 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  svc was 91%. inspiratory capacity was 70%.  residual volume was 225% of its predicted.  total lung capacity was 128%.  ,impression:,1.  moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  probably there is some restrictive element because of fibrosis.  the reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  diffusion capacity was not measured.  the flow volume loop was consistent with the above.,",2
"chief complaint:, ""trouble breathing."",history of present illness:, a 37-year-old german woman was brought to a shock room at the general hospital with worsening shortness of breath and cough. over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. she had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. on the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. on arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. she denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. she denied any history of ivda, tattoos, or high risk sexual behavior. she did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an ivc filter had been placed in germany . she had been living in the united states for years, and had had no recent travel. she denied any occupational exposures. before the onset of her shortness of breath she had been very active and had exercised regularly.,past medical history:,  pulmonary embolism in 1997 which had been treated with thrombolysis in germany. she reported that she had been on warfarin for 6 months after her diagnosis.  recurrent venous thromboembolism in 1999 at which time an ivc filter had been placed.  psoriasis.  she denied any history of miscarriage.,past surgical history:,  ivc filter placement 1999.",14
"chief complaint: , septal irritation.,history of present illness: , the patient is a 39-year-old african-american female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  the patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a ""stretching"" like pressure.  she says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  she has no other complaints at this time.,physical exam:,general:  this is a pleasant african-american female resting in the examination room chair in no apparent distress.,ent:  external auditory canals are clear.  tympanic membrane shows no perforation, is intact.,nose:  the patient has a slightly deviated right septum.  septum has a large perforation in the anterior 2/3rd of the septum.  this appears to be well healed.  there is no sign of crusting in the nose.,oral cavity:  no lesions or sores.  tonsils show no exudate or erythema.,neck:  no cervical lymphadenopathy.,vital signs:  temperature 98 degrees fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,assessment and plan:  ,the patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  at this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  at this time, i counseled the patient on the risks and benefits of surgery.  she will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a q-tip.  we will see her back in 3 weeks and if the patient does not feel relieved from the bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.",10
"chief complaint: , chronic low back, left buttock and leg pain.,history of present illness: , this is a pleasant 49-year-old gentleman post lumbar disc replacement from january 2005.  unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain.  he has also tried acupuncture, tens unit, physical therapy, chiropractic treatment and multiple neuropathic medications including elavil, topamax, cymbalta, neurontin, and lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain.  most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the botox procedure that was done on march 8, 2006 has not given him any relief from his buttock pain.  he states that approximately 75% of his pain is in his buttock and leg and 25% in his back.  he has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back.  he rated his pain today as 6/10, describing it is shooting, sharp and aching.  it is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication.  it is constant but variable in degree.  it continues to affect activities and sleep at night as well as mood at times.  he is currently not satisfied completely with his level of pain relief.,medications: , kadian 30 mg b.i.d., zanaflex one-half to one tablet p.r.n. spasm, and advil p.r.n.,allergies:,  no known drug allergies.,review of systems:,  complete multisystem review was noted and signed in the chart.,social history:,  unchanged from prior visit.,physical examination: , blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs.  he is a well-developed obese male in no acute distress.  he is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression.  he ambulates with normal gait and has normal station.  he is able to heel and toe walk.  he denies any sensory changes.,assessment & plan: , this is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints.  we discussed treatment options at length and he is willing to undergo a trial of lyrica.,he is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime.  we discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him.  we also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him.  he will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.",25
"cc:, weakness.,hx:, this 30 y/o rhm was in good health until 7/93, when he began experiencing rue weakness and neck pain. he was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. he then went to a local neurosurgeon and a cervical spine ct scan, 9/25/92, revealed an intramedullary lesion at c2-3 and an extramedullary lesion at c6-7. he underwent a c6-t1 laminectomy with exploration and decompression of the spinal cord. his clinical condition improved over a 3 month post-operative period, and then progressively worsened. he developed left sided paresthesia and upper extremity weakness (right worse than left). he then developed ataxia, nausea, vomiting, and hyperreflexia. on 8/31/93, mri c-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. on 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. his symptoms stabilized and he underwent 5040 cgy in 28 fractions to his brain and 3600 cgy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,he was evaluated in the neurooncology clinic on 10/26/95 for consideration of chemotherapy. he complained of progressive proximal weakness of all four extremities and dysphagia. he had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). he had difficulty going down stairs, but could climb stairs. he had no bowel or bladder incontinence or retention.,meds:, none.,pmh:, see above.,fhx:, father with von hippel-lindau disease.,shx:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. he is divorced and has two sons who are healthy. he lives with his mother.,ros:, noncontributory.,exam:, vital signs were unremarkable.,ms: a&o to person, place and time. speech fluent and without dysarthria. thought process lucid and appropriate.,cn: unremarkable exept for 4+/4+ strength of the trapezeii. no retinal hemangioblastoma were seen.,motor: 4-/4- strength in proximal and distal upper extremities. there is diffuse atrophy and claw-hands, bilaterally. he is unable to manipulate hads to any great extent. 4+/4+ strength throughout ble. there is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,sensory: there was a right t3 and left t8 cord levels to pp on the posterior thorax. decreased lt in throughout the 4 extremities.,coord: difficult to assess due to weakness.,station: bue pronator drift.,gait: stands without assistance, but can only manage to walk a few steps. spastic gait.,reflexes: hyperreflexic on left (3+) and hyporeflexic on right (1). babinski signs were present bilaterally.,gen exam: unremarkable.,course: ,9/8/95, gs normal. by 11/14/95, he required ngt feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.mri brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. there were postoperative changes and a cyst in the medulla.,on 10/25/96, he presented with a 1.5 week h/o numbness in ble from the mid- thighs to his toes, and worsening ble weakness. he developed decubitus ulcers on his buttocks. he also had had intermittent urinary retention for month, chronic sob and dysphagia. he had been sitting all day long as he could not move well and had no daytime assistance. his exam findings were consistent with his complaints. he had had no episodes of diaphoresis, headache, or elevated blood pressures. an mri of the c-t spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to t10. there was evidence of prior cervical laminectomy of c6-t1 with expansion of the cord in the thecalsac at that region. multiple intradural extra spinal nodular lesions (hyperintense on t2, isointense on t1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. the largest of which measures 1.1 x 1.0 x 2.0cm. there are also several large ring enhancing lesions in cerebellum. the lesions were felt to be consistent with hemangioblastoma. no surgical or medical intervention was initiated. visiting nursing was provided. he has since been followed by his local physician",31
"chief complaint: , ""i have had trouble breathing for the past 3 days"",history: , 69-year-old caucasian male complaining of difficulty breathing for 3 days.  he also states that he has been coughing accompanying with low-grade type fever.  he also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,pmh: , dm, htn, copd, cad,psh:  ,cabg, appendectomy, tonsillectomy,fh:,  non-contributory,soch: , divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  he smokes 1 pack a day of newport for 30 years and is a social drinker.  he denies any illicit drug use.,travel history: , denies any recent travel overseas,allergies: , denies any drug allergies,home medications:,  advair 1 puff bid lisinopril 10 mg qd lopressor 50 mg bid aspirin 81 mg qd plavix 75 mg qd multivitamins feso4 1 tab qd colace 100 mg qd,review of systems reveals:,  same as above,physical exam:,vital signs are:  temp.  99.3 f / bp 138/92, resp.  22, p 88,general:  patient is in mild acute respiratory distress,heent:,head:  atraumatic, normocephalic,,eyes:",14
"diagnosis:,  stasis ulcers of the lower extremities,operation:,  split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,indications:,  this 84-year old female presented recently with large ulcers of the lower extremities.  these were representing on the order of 50% or more of the circumference of her lower leg.  they were in a distribution to be consistent with stasis ulcers.  they were granulating nicely and she was scheduled for surgery.,findings:,  large ulcers of lower extremities with size as described above.  these are irregular in shape and posterior and laterally on the lower legs.  there was no evidence of infection.  the ultimate skin grafting was quite satisfactory.,procedure: , having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  the legs were examined and the wounds were pulsavaced bilaterally with 3 liters of saline with bacitracin.  the wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  this was meshed 1:1.5 and then stapled into position on the wounds.  the wounds were then dressed with a fine mesh gauze that was stapled into position as well as kerlix soaked in sulfamylon solution.,she was then dressed in additional kerlix, followed by webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  the donor site was dressed with op-site.  the patient tolerated the procedure well and returned to the recovery room in satisfactory condition.",5
"preoperative diagnosis: , bilateral pleural effusion.,postoperative diagnosis: , bilateral pleural effusion.,procedure performed: ,removal of bilateral #32-french chest tubes with closure of wound.,complications:,  none.,indications for procedure: , the patient is a 66-year-old african-american male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  a decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  the patient was agreeable to proceed.,operative procedure:  ,the patient was prepped and draped at the bedside over both chest tube sites.  the pressures applied over the sites and the skin was closed with interrupted #3-0 ethilon sutures.  the skin was then cleansed and vaseline occlusive dressing was applied over the sites.  the same procedure was performed on the other side.  the chest tubes were removed on full inspiration.  vital signs remained stable throughout the procedure.  the patient will remain in the intensive care unit for continued monitoring.,",2
"preprocedure diagnosis: , colon cancer screening.,postprocedure diagnosis:  ,colon polyps, diverticulosis, hemorrhoids.,procedure performed: , colonoscopy, conscious sedation, and snare polypectomy.  ,indications:  ,the patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  he has had previous colonoscopy.  there is no family history of bleeding, no current problems with his bowels.  on examination, he has internal hemorrhoids.  his prostate is enlarged and increased somewhat in firmness.  he has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  these were removed with snare polypectomy technique.  i would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,procedure: , after explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg versed intravenously for conscious sedation.  blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  a rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  the scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  the scope was withdrawn into the left transverse colon, where the second polyp was identified.  it was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  the scope was then gradually withdrawn the remaining distance and removed.  the patient tolerated the procedure well.",13
"preoperative diagnosis:,  right ac separation.,postoperative diagnosis:,  right ac separation.,procedures:,  removal of the hardware and revision of right ac separation.,anesthesia:,  general.,blood loss:,  100 cc.,complications:,  none.,findings: , loose hardware with superior translation of the clavicle implants.,implants: , arthrex bioabsorbable tenodesis screws.,summary: , after informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  after uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  the incision was reopened and the hardware was removed without difficulty.  the ac joint was inspected and reduced.  an allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  and two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  this provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  the wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  he was awakened from anesthesia and taken to recovery room in a stable condition.,final needle and instrument counts were correct.",25
"preoperative diagnosis: , acute appendicitis.,postoperative diagnosis: , acute appendicitis.,operative procedure:,  laparoscopic appendectomy.,intraoperative findings: , include inflamed, non-perforated appendix.,operative note:  ,the patient was seen by me in the preoperative holding area.  the risks of the procedure were explained.  she was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  general anesthesia was carried out without difficulty and a foley catheter was inserted.  the left arm was tucked and the abdomen was prepped with betadine and draped in sterile fashion.  a 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  once we were inside the abdominal cavity, co2 was instilled to attain an adequate pneumoperitoneum.  a left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  the 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  the base of the cecum was acutely inflamed but not perforated.  i then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  the window is big enough to get an endo gia blue cartridge through it and fired across the base of the mesoappendix without difficulty.  i reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  i then placed the appendix in an endobag and brought out through the suprapubic port without difficulty.  i reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  one final inspection revealed no bleeding from the staple line.  we then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  the pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-vicryl suture.  the skin incision was injected with 0.25% marcaine and closed with 4-0 monocryl suture.  steri-strips and sterile dressings were applied.  no complications.  minimal blood loss.  specimen is the appendix.  brought to the recovery room in stable condition.",13
"chief complaint: , ""bloody bump on penis."",history of present illness: , this is a 29-year-old african-american male who presents to the emergency department today with complaint of a bleeding bump on his penis.  the patient states that he has had a large bump on the end of his penis for approximately a year and a half.  he states that it has never bled before.  it has never caused him any pain or has never been itchy.  the patient states that he is sexually active, but has been monogamous with the same person for the past 13 years.  he states that he believes that his sexual partner is monogamous as well and reciprocates in this practice.  the patient does state that last night he was ""trying to get some,"" meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis.  the patient said that there is a large amount of blood from this injury.  this happened last night, but he was embarrassed to come to the emergency department yesterday when it was bleeding.  the patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed.  the patient denies any drainage or discharge from his penis.  he denies fevers or chills recently.  he also denies nausea or vomiting.  the patient has not had any discharge from his penis.  he has not had any other skin lesions on his penis that are new to him.  he states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years.  the patient has never had these checked out.  he denies fevers, chills, or night sweats.  he denies unintentional weight gain or loss.  he denies any other bumps, rashes, or lesions throughout the skin on his body.,past medical history:  ,no significant medical problems.,past surgical history: , surgery for excision of a bullet after being shot in the back.,social habits: , the patient denies illicit drug usage.  he occasionally smokes tobacco and drinks alcohol.,medications: , none.,allergies: , no known medical allergies.,physical examination:  ,general:  this is an african-american male who appears his stated age of 29 years.  he is well nourished, well developed, in no acute distress.  the patient is pleasant.  he is sitting on a emergency department gurney.,vital signs:  temperature 98.4 degrees fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,heart:  regular rate and rhythm.  clear s1, s2.  no murmur, rub, or gallop is appreciated.,lungs:  clear to auscultation bilaterally.  no wheezes, rales, or rhonchi.,abdomen:  soft, nontender, nondistended, and positive bowel sounds throughout.,genitourinary:  the patient's external genitalia is markedly abnormal.  there is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus.  this pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter.  the patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well.  there are no open lesions at this point.  there is a small tear of the skin where the mass attaches to the glans near the urethral meatus.  bleeding is currently stanch, and there is no sign of secondary infection at this time.  bilateral testicles are descended and normal without pain or mass bilaterally.  there is no inguinal adenopathy.,extremities:  no edema.,skin:  warm, dry, and intact.  no rash or lesion.,diagnostic studies:  ,non-emergency department courses.  it is thought that this patient should proceed directly with a referral to urology for excision and biopsy of this mass.,assessment and plan: , penile mass.  the patient does have a large pedunculated penile mass.  he will be referred to the urologist who is on-call today.  the patient will need this mass excised and biopsied.  the patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the er.,",11
"reason for consult: , essential tremor and torticollis.,history of present illness: , this is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  she remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  she thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  she has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  since around 6 to 7 years, she has had a head tremor, which is mainly ""no- no"" and occasional voice tremor also.  additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  she also has some stress incontinence.  last mri brain was done in 2001 reportedly normal.,current medications:,1.  klonopin 0.5 mg twice a day.,2.  primidone 100 mg b.i.d.,3.  propranolol long-acting 80 mg once in the morning.,past medical history: , essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,past surgical history: , l5-s1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,family history: , both parents have et and hypertension.  maternal cousin with lupus.,social history: , denies any smoking or alcohol.  she is married since 44 years, has 3 children.  she used to work as a labor and delivery nurse up until early 2001 when she retired.,review of systems: , no fever, chills, nausea or vomiting.  no visual complaints.  she complains of hearing decreased on the left.  no chest pain or shortness of breath.  no constipation.  she does give a history of urge incontinence.  no rashes.  no depressive symptoms.,physical examination:,vital signs:  blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  heent:  perrla.  eomi.  cardiovascular:  s1 and s2 normal.  regular rate and rhythm.  she does have a rash over the right ankle with a prior basal cell carcinoma was resected.  neurologic:  alert and oriented x4.  speech shows a voice tremor occasionally.  language is intact.  cranial nerves ii through xii intact.  motor examination showed 5/5 power in all extremities with minimal increased tone.  sensory examination was intact to light touch.  reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  her coordination showed minimal intentional component to bilateral finger-to-nose.  gait was intact.  lot of swing on romberg's.  the patient did have a tremor both upper extremities, right more than left.  she did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,assessment and plan: , this 62-year-old white female has essential tremor and mild torticollis.  tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  the patient did not wish to change any of her medication doses at this point.  we will go ahead and check mri brain, and we will get the films later.  we will see her back in 3 months.  also, the patient declined any possible botox for the mild torticollis she has at this point.",20
"preoperative diagnosis: , cholecystitis and cholelithiasis.,postoperative diagnosis:  ,cholecystitis and cholelithiasis.,title of procedure,1.  laparoscopic cholecystectomy.,2.  intraoperative cholangiogram.,anesthesia:  ,general.,procedure in detail:  ,the patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  the patient received 1 gm of iv ancef intravenously piggyback.  the abdomen was prepared and draped in routine sterile fashion.,a 1-cm incision was made at the umbilicus and a veress needle was inserted.  saline test was performed.  satisfactory pneumoperitoneum was achieved by insufflation of co2 to a pressure of 14 mmhg.  the veress needle was removed.  a 10- to 11-mm cannula was inserted.  inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  it was largely mobile.  the liver had a normal appearance as did the peritoneal cavity.  a 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  a second 5-mm cannula was inserted in the subcostal space.  a 10- to 11-mm cannula was inserted into the upper midline.,the gallbladder was reflected in a cephalad direction.  the gallbladder was punctured with the aspirating needle, and under c-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  extra contrast was aspirated and the aspirating needle was removed.  the ampulla was grasped with a second grasper, opening the triangle of calot.  the cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  this was done while the common duct was in full visualization.  the cystic artery was similarly controlled and divided.  the gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,the subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  there was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  the subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  hemostasis was excellent.  co2 was evacuated and the camera removed.  the umbilical fascia was closed with 2-0 vicryl, the subcu with 3-0 vicryl, and the skin was closed with 4-0 nylon.  sterile dressings were applied.  sponge and needle counts were correct.",36
"history of present illness:,  this is a 1-year-old male patient who was admitted on 12/23/2007 with a history of rectal bleeding.  he was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool.  he had one more episode that day of stool; the stool was hard with blood in it.  then, he had one episode of rectal bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it.  no history of fever, no diarrhea, no history of easy bruising.  excessive bleeding from minor cut.  he has been slightly fussy.,past medical history:  ,nothing significant.,pregnancy delivery and nursery course: , he was born full term without complications.,past surgical history: , none.,significant illness and review of systems: , negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.,diet:,  regular table food, 24 ounces of regular milk.  he is n.p.o. now.,travel history: , negative.,immunization: , up-to-date.,allergies: , none.,medications: , none, but he is on iv zantac now.,social history: , he lives with parents and siblings.,family history:,  nothing significant.,laboratory evaluation: , on 12/24/2007, wbc 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000.  sodium 135, potassium 4.7, chloride 110, co2 20, bun 6 and creatinine 0.3.  albumin 3.3.  ast 56 and alt 26.  crp less than 0.3.  stool rate is still negative.,diagnostic data: , ct scan of the abdomen was read as normal.,physical examination:  ,vital signs:  temperature 99.5 degrees fahrenheit, pulse 142 per minute and respirations 28 per minute.  weight 9.6 kilogram.,general:  he is alert and active child in no apparent distress.,heent:  atraumatic and normocephalic.  pupils are equal, round and reactive to light.  extraocular movements, conjunctivae and sclerae fair.  nasal mucosa pink and moist.  pharynx is clear.,neck:  supple without thyromegaly or masses.,lungs:  good air entry bilaterally.  no rales or wheezing.,abdomen:  soft and nondistended.  bowel sounds positive.  no mass palpable.,genitalia:  normal male.,rectal:  deferred, but there was no perianal lesion.,musculoskeletal:  full range of movement.  no edema.  no cyanosis.,cns:  alert, active and playful.,impression: , a 1-year-old male patient with history of rectal bleeding.  possibilities include meckel's diverticulum, polyp, infection and vascular malformation.,plan:,  to proceed with meckel scan today.  if meckel scan is negative, we will consider upper endoscopy and colonoscopy.  we will start colon clean out if meckel scan is negative.  we will send his stool for c. diff toxin, culture, blood for rast test for cow milk, soy, wheat and egg.  monitor hemoglobin.",13
"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.",7
"history of present illness:,  patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  he attempted to remove it with tweezers at home, but was unsuccessful.  he is requesting we attempt to remove this for him.,the patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with ""horse serum.""  consequently, he has declined to update his tetanus immunization.,medications: , he is currently on several medications, a list of which is attached to the chart, and was reviewed.  he is not on any blood thinners.,allergies: , he is allergic only to tetanus serum.,social history: , patient is married and is a nonsmoker and lives with his wife.  ,nursing notes were reviewed with which i agree.,physical examination,vital signs:  temp and vital signs are all within normal limits.,general:  the patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,extremities:  exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  it does not protrude beyond the end of the nail plate.  there is no active bleeding.  there is no edema or erythema of the digit tip.  flexion and extension of the dip joint is intact.  the remainder of the hand is unremarkable.,treatment: , i did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  in order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  consequently, the base of the digit tip was prepped with betadine, and just distal to the dip joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  i was able to grasp the splinter and remove this.  no further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,assessment: , foreign body of the left fifth fingernail (wooden splinter).,plan: , patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a band-aid.  if he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.",4
"long-term goals:,  both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  this goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  during the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  she continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,the patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  the patient and her husband both agreed with the patient's discharge.",35
"exam:,  ct abdomen & pelvis w&wo contrast, ,reason for exam: , status post aortobiiliac graft repair. , ,technique: , 5 mm spiral thick spiral ct scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  no oral or rectal contrast was utilized.  comparison is made with the prior ct abdomen and pelvis dated 10/20/05.  there has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 ap.  just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  the size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  there is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  no exoluminal leakage is identified at any level.  there is no retroperitoneal hematoma present.  the findings are unchanged from the prior exam.  ,the liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  there is advanced atrophy of the left kidney.  no hydronephrosis is present.  no acute findings are identified elsewhere in the abdomen. ,the lung bases are clear. ,concerning the remainder of the pelvis, no acute pathology is identified.  there is prominent streak artifact from the left total hip replacement.  there is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  the bladder grossly appears normal.  a hysterectomy has been performed.  ,impression:,1.  no complications identified regarding endoluminal aortoiliac graft repair as described.  the findings are stable compared to the study of 10/20/04.  ,2.  stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  no other acute findings noted. ,4.  advanced left renal atrophy.",31
"preoperative diagnoses:,1.  right carpal tunnel syndrome.,2.  right index finger and middle fingers tenosynovitis.,postoperative diagnoses:,1.  right carpal tunnel syndrome.,2.  right index finger and middle fingers tenosynovitis.,procedures performed:,1.  right carpal tunnel release.,2.  right index and middle fingers release a1 pulley.,tourniquet time:  ,70 minutes.,blood loss: , minimal.,gross intraoperative findings:,1.  a compressed median nerve at the carpal tunnel, which was flattened.,2.  a stenosing tenosynovitis of the a1 pulley of the right index as well as middle fingers.  after the a1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,history:  ,this is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  the patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  he had positive emg findings as well as clinical findings.  the patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,all risks as well as complications were discussed with the patient and consent was obtained.,procedure:  ,the patient was wheeled back to the operating room #1 at abcd general hospital on 08/29/03.  he was placed supine on the operating room table.  next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  at this time, 8 cc of 0.25% marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  in addition, an additional 2 cc were used on the superficial skin of the volar palm over the a1 pulley of the right index and right middle fingers.  at this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  first, we went for release of the carpal tunnel.  approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  first, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to ragnells retracting proximally and distally.  the palmaris brevis muscle was then identified and sharply transected.  at this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  the resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  at this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  at this time, copious irrigation was used to irrigate the wound.  the wound was suctioned dry.  at this time, we proceeded to the release of the a1 pulleys.  approximately, a 1.5 cm incision was made over the a1 pulley in the volar aspect of the palm of the right index and right middle fingers.  first, we went for the index finger.  once the skin incision was made, metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with ragnell retractors we identified the a1 pulley.  a #15 blade was used to make a longitudinal slit along with a1 pulley and the littler scissors were used to release the a1 pulley proximally as well as distally.  once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  there was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  once a thorough release was performed, copious irrigation was used to irrigate that wound.  in the similar fashion, a 1.5 cm incision was made over the volar aspect of the a1 pulley of the right middle finger.  a littler scissor was used to bluntly dissect in the longitudinal fashion.  with the ragnell retractors, we identified the a1 pulley of the right middle finger.,using a #15 blade, the a1 pulley was scored with the #15 blade and the litter scissor was used to complete the release of the a1 pulley distally and proximally.  we again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  again, there was evidence of some synovitis as well as fraying of both tendons.  the girth of both tendons and both wounds were within normal limits.  at this time, copious irrigation was used to irrigate the wound.  the patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  in addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  at this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both a1 pulley incisions of the right middle finger and right index finger.  the wound closure took place after the tourniquet was released and hemostasis was obtained with bovie cautery.  at this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of adaptic and kerlix roll.  the patient was then carefully taken off of the operating room table to recovery in stable condition.",25
"preoperative diagnoses: , epiretinal membrane, right eye.  cme, right eye.,postoperative diagnoses: , epiretinal membrane, right eye.  cme, right eye.,procedures: , pars plana vitrectomy, membrane peel, 23-gauge, right eye.,preoperative findings:,  the patient had epiretinal membrane causing cystoid macular edema.  options were discussed with the patient stressing that the visual outcome was guarded.  especially since this membrane was of chronic duration there is no guarantee of visual outcome.,description of procedure: , the patient was wheeled to the or table.  local anesthesia was delivered using a retrobulbar needle in an atraumatic fashion 5 cc of xylocaine and marcaine was delivered to retrobulbar area and massaged and verified.  preparation was made for 23-gauge vitrectomy, using the trocar inferotemporal cannula was placed 3.5 mm from the limbus and verified.  the fluid was run.  then superior sclerotomies were created using the trocars and 3.5 mm from the limbus at 10 o'clock and 2 o'clock.  vitrectomy commenced and carried on as far anteriorly as possible using intraocular forceps, ilm forceps, the membrane was peeled off in its entirety.  there were no complications.  dvt precautions were in place.  i, as attending, was present in the entire case.",24
"subjective:,",14
"preoperative diagnosis:,  prostate cancer, gleason score 4+3 with 85% burden and 8/12 cores positive.,postoperative diagnosis:,  prostate cancer, gleason score 4+3 with 85% burden and 8/12 cores positive.,procedure done: , open radical retropubic prostatectomy with bilateral lymph node dissection.,indications:,  this is a 66-year-old gentleman who had an elevated psa of 5.  his previous psas were in the 1 range.  trus biopsy revealed 4+3 gleason score prostate cancer with a large tumor burden.  after extensive counseling, the patient elected for retropubic radical prostatectomy.  given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  the patient consented and agreed to proceed forward.,description of procedure: , the patient was brought to the operating room here.  time out was taken to properly identify the patient and procedure going to be done.  general anesthesia was induced.  the patient was placed in the supine position.  the bed was flexed distant to the pubic area.  the patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with hibiclens soap for three minutes.  the patient was then prepped and draped in normal sterile fashion.  foley catheter was inserted sterilely in the field.  preoperative antibiotics were given within 30 minutes of skin incision.  a 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  dissection was taken down through scarpa's fascia to the level of the anterior rectus sheath.  the rectus sheath was then incised and the muscle was split in the middle.  space of rectus sheath was then entered.  the bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  the lymph node packet on the left side was then dissected.  this was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  the proximal extent of dissection was the left hypogastric artery to the level of the node of cloquet distally.  care was taken to avoid injury to the nerves.  an accessory obturator vein was noted and was ligated.  the same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  the bladder subsequently was retracted cephalad.  the prostate was then defatted up to the level of the endopelvic fascia.  the endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  a babcock was then applied around the dorsal venous complex over the urethra and the k-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  a 0-vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  using a knife on a long handle, the dorsal venous complex was then incised using the k-wire as a guide.  following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the foley catheter.  the 3-0 monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  the lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  the catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  the urethra was subsequently divided in its entirety.  a foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  the prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  throughout the case, the bleeding was controlled with the aid of a clips, vicryl sutures, silk sutures, and ties, direct pressure packing, and floseal.  following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and denonvilliers' fascia.  the seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  care was taken throughout the posterior dissection to preserve the integrity of the ureters.  the anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  following the dissection, the 5-french feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  the bladder neck was then repaired using vicryl in a tennis racquet fashion.  the rest of the mucosa was then everted.  the ureteral orifices and ureters were protected throughout the procedure.  at this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  hemostasis was then adequately obtained.  floseal was applied to the pelvis.  the bladder was then irrigated.  it was draining pink urine.  the wound was copiously irrigated.  the fascia was then closed using a #1 looped pds.  the skin wound was then irrigated, and the skin was closed with a 4-0 monocryl in subcuticular fashion.  at this point, the procedure was terminated with no complications.  the patient was then extubated in the operating room and taken in stable condition to the pacu.  please note that during the case about 3600 ml of blood was noted.  this was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.",36
"chief complaint:,  essential thrombocytosis.,history of present illness: , this is an extremely pleasant 64-year-old gentleman who i am following for essential thrombocytosis.  he was first diagnosed when he first saw a hematologist on 07/09/07.  at that time, his platelet count was 1,240,000.  he was initially started on hydrea 1000 mg q.d.  on 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  he was positive for the jak-2 mutation.  on 11/06/07, his platelets were noted to be 766,000.  his current hydrea dose is now 1500 mg on mondays and fridays and 1000 mg on all other days.  he moved to abcd in december 2009 in an attempt to improve his wife's rheumatoid arthritis.,overall, he is doing well.  he has a good energy level, and his ecog performance status is 0.  he denies any fevers, chills, or night sweats.  no lymphadenopathy.  no nausea or vomiting.  no change in bowel or bladder habits.,current medications: , hydrea 1500 mg on mondays and fridays and 1000 mg the other days of the week,  flomax q.d., vitamin d q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin c q.d.,allergies: , no known drug allergies.,review of systems:,  as per the hpi, otherwise negative.,past medical history:,1.  he is status post an appendectomy.,2.  status post a tonsillectomy and adenoidectomy.,3.  status post bilateral cataract surgery.,4.  bph.,social history:  ,he has a history of tobacco use, which he quit at the age of 37.  he has one alcoholic drink per day.  he is married.  he is a retired lab manager.,family history:  ,there is no history of solid tumor or hematologic malignancies in his family.,physical exam:,vit:",15
"preoperative diagnoses,1.  postoperative wound infection.,2.  left gluteal abscess.,3.  intraperitoneal pigtail catheter.,postoperative diagnoses,1.  postoperative wound infection.  there was an intraperitoneal foreign body.,2.  left gluteal abscess.,3.  intraperitoneal pigtail catheter.,procedures,1.  incision and drainage (i&d) of gluteal abscess.,2.  removal of pigtail catheter.,3.  limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,description of procedure: , after obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed.  under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion.  the opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward.  i proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,then, the patient was placed in a supine position, and i proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism.  it came out without any difficulty.  then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion.  my initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision.  i initially probed the wound with a hemostat and this had at least 12 cm long tract and i proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and i realized that the sinus tract was going through the fascia into the abdomen.  very carefully, i started dividing the fascia.  of course, there were several small bowel loops adhered to the area.  the dissection was quite tedious for a while.  initially, i thought that may be there was an enterocutaneous fistula in the area, but then i realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract.  i made a laparotomy of about 10 cm and i carefully dissected the bowel of the fascia.  there was an area at the bottom which looked like a foreign body and initially i thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to pathology for examination.  initially, i have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,i was very happy that we were not really dealing with enterocutaneous fistula.  the area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy pps.  the subcutaneous tissue and the skin were left open and packed with betadine-soaked sponges.,a dressing was applied.  a small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area.  the patient tolerated the procedure well.  estimated blood loss was minimal, and he was sent to the icu and also made acute care because of the need for a laparotomy, which we were not anticipating.",36
"post procedure instructions:, the patient has been asked to report to us any redness, swelling, inflammation, or fevers.  the patient has been asked to restrict the use of the * extremity for the next 24 hours.",26
"subjective:,  this is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes.  she did attend diabetes education classes at abc clinic.  she comes however, wanting to really work at weight reduction.  she indicates that she has been on the atkins' diet for about two years and lost about ten pounds.  she is now following a veggie diet which she learned about in poland originally.  she has been on it for three weeks and intends to follow it for another three weeks.  this does not allow any fruits or grains or starchy vegetables or meats.  she does eat nuts for protein.  she is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet.  she also wants to know that if she gets skinny enough, if the diabetes will go away.  her problem time, blood sugar wise, is in the morning.  she states that if she eats too much in the evening that her blood sugars are always higher the next morning.,objective:,  weight:  189 pounds.  reported height:  5 feet 5 inches.  bmi is approximately 31-1/2.  diabetes medications include metformin 500 mg daily.  lab from 5/12/04:  hemoglobin a1c was 6.4%.,a diet history was obtained.  i instructed the patient on dietary guidelines for weight reduction.  a 1200-calorie meal plan was recommended.,assessment:,  patient's diet history reflects that she is highly restricting carbohydrates in her food intake.  she does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning.  this primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts.  she is doing some physical activity two to three times a week.  this includes aerobic walking with weights on her arms and her ankles.  she is likely going to need to increase frequency in this area to help support weight reduction.  her basal metabolic rate was estimated at 1415 calories a day.  her total calorie requirements for weight maintenance are estimated at 1881 calories a day.  a 1200-calorie meal plan should support a weight loss of at least one pound a week.,plan:,  recommend patient increase the frequency of her walking to five days a week.  encouraged a 30-minute duration.  also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations.  and lastly, i encouraged caloric intake of just under 1200 calories daily.  recommend keeping food records and tracking caloric intake.  it is unlikely that her blood sugars would drop significantly low on the current dose of glucophage.  however, i encouraged her to be careful not to reduce calories below 1000 calories daily.  she may want to consider a multivitamin as well.  this was a one-hour consultation.",4
"preoperative diagnosis:,  osteomyelitis, right hallux.,postoperative diagnosis: , osteomyelitis, right hallux.,procedure performed:,  amputation distal phalanx and partial proximal phalanx, right hallux.,anesthesia:,  tiva/local.,history:,  this 44-year-old male patient was admitted to abcd general hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  the patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  the patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  the patient desires to attempt a surgical correction.  the risks versus benefits of the procedure were discussed with the patient in detail by dr. x.  the consent was available on the chart for review.,procedure in detail: , after patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  adequate iv sedation was administered by the department of anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% marcaine plain were injected into the right hallux as a digital block.  the foot was prepped and draped in the usual aseptic fashion lowering the operative field.,attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  there was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  the toe was 2.5 times to the normal size.  there were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  the patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  x-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  a #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  the incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  the distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  this bone was also sent off for culture and was labeled proximal margin.  next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  the flexor tendon distally was gray discolored and was not viable.  a hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  none was found.  no purulent drainage or abscess was found.  the proximal margin of the surgical site tissue was viable and healthy.  there was no malodor.  anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,a #3-0 vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  the plantar flap was viable and was debulked with metzenbaum scissors.  the flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  iris scissors were used to modify and remodel the plantar flap.  an excellent cosmetic result was achieved.  no tourniquet was used in this case.  the patient tolerated the above anesthesia and surgery without apparent complications.  a standard postoperative dressing was applied consisting of saline-soaked owen silk, 4x4s, kerlix, and coban.  the patient was transported via cart to postanesthesia care unit with vital signs able and vascular status intact to right foot.  he will be readmitted to dr. katzman where we will continue to monitor his blood pressure and regulate his medications.  plan is to continue the antibiotics until further iv recommendations.,he will be nonweightbearing to the right foot and use crutches.  he will elevate his right foot and rest the foot, keep it clean and dry.  he is to follow up with dr. x on monday or tuesday of next week.",36
"protocol:,  bruce.,pertinent medication: , none.,reason for test:,  chest pain.,procedure and interpretation: ,1.  baseline heart rate:  67.,2.  baseline blood pressure:  150/86.,3.  total time:  6 minute 51 seconds.,4.  mets:  10.1.,5.  peak heart rate:  140.,6.  percent of maximum-predicted heart rate:  90.,7.  peak blood pressure:  200/92.,8.  reason test terminated:  shortness of breath and fatigue.,9.  estimated aerobic capacity:  average.,10. heart rate response:  normal.,11. blood pressure response:  hypertensive.,12. st segment response:  normal.,13. chest pain:  none.,14. symptoms:  none.,15. arrhythmia:  none.,conclusion:,1.  average aerobic capacity.,2.  normal heart rate and blood pressure response to exercise.,3.  no symptomatic electrocardiographic evidence of ischemia.,condition: , stable with normal vital signs.,disposition:  ,the patient was discharged home and was asymptomatic.,",31
"1.  pelvic tumor.,2.  cystocele.,3.  rectocele.,postoperative diagnoses:,1.  degenerated joint.,2.  uterine fibroid.,3.  cystocele.,4.  rectocele.,procedure performed:  ,1.  total abdominal hysterectomy.,2.  bilateral salpingooophorectomy.,3.  repair of bladder laceration.,4.  appendectomy.,5.  marshall-marchetti-krantz cystourethropexy.,6.  posterior colpoperineoplasty.,gross findings:  the patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  she had a recent d&c and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  curettings were negative for malignancy.  the patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  the ovaries appeared to be within normal limits.  there was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  no other pathology noted from the abdominal cavity or adhesions.  the upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  the appendix is in its normal anatomic position.  the ileum was within normal limits with no meckel's diverticulum seen and no other gross pathology evident.  there was no evidence of metastasis or tumors in the left lobe of the liver.,upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,operative procedure:  the patient was taken to the operating room, prepped and draped in the low lithotomy position under general anesthesia.  a midline incision was made around the umbilicus down to the lower abdomen.  with a #10 bard parker blade knife, the incision was carried down through the fascia.  the fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 bard parker blade after incision was made with mayo scissors.  a balfour retractor was placed into the wound.  this giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  the infundibular ligament on the right side was isolated and ligated with #0 vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 vicryl suture.  the right round ligament was ligated with #0 vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  the infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  an attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  after this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  the bladder was then repaired with a running locking stitch #0 vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 vicryl suture.  after removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight ochsner forceps and divided from the uterus with mayo scissors, and the straight ochsner was placed by #0 vicryl suture thus controlling the uterine blood supply.  the cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved ochsner forceps, divided from the uterus with #10 bard parker blade knife and a curved ochsner was placed by #0 vicryl suture.  the cervix was again grasped with a lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 bard parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  a single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  the vaginal cuff was then closed using a running #0 vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  the round ligaments were approximated to the vaginal cuff with #0 vicryl suture and the bladder flap approximated to the round ligaments with #000 vicryl suture.  the ______ was re-peritonealized with #000 vicryl suture and then the cecum brought into the incision.  the pelvis was irrigated with approximately 500 cc of water.  the appendix was grasped with babcock forceps.  the mesoappendix was doubly clamped with curved hemostats and divided with metzenbaum scissors.  the curved hemostats were placed with #00 vicryl suture.  the base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 bard parker blade knife, and the base inverted with a pursestring suture with #00 vicryl.  no bleeding was noted.  sponge, instrument, and needle counts were found to be correct.  all packs and retractors were removed.  the peritoneum muscle fascia was closed in single-layer closure using running looped #1 pds, but prior to closure, a marshall-marchetti-krantz cystourethropexy was carried out by dissecting the space of retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 vicryl suture.  following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  attention was then turned to the vagina, where the introitus of the vagina was grasped with an allis forceps at the level of the bartholin glands.  an incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with metzenbaum scissors.  the flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  in this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 vicryl suture.  excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 vicryl suture.  the bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 vicryl suture.  the skin was closed with a running #000 plain gut subcuticular stitch.  the vaginal vault was packed with a betadine-soaked kling gauze sponge.  sterile dressing was applied.  the patient was sent to recovery room in stable condition.",37
"preoperative diagnosis: , right inguinal hernia. ,postoperative diagnosis:,  right direct inguinal hernia. ,procedure:,  right direct inguinal hernia repair with phs mesh system. ,anesthesia:,  general with endotracheal intubation. ,procedure in detail: , the patient was taken to the operating room and placed supine on the operating table.  general anesthesia was administered with endotracheal intubation.  the right groin and abdomen were prepped and draped in the standard sterile surgical fashion.  an incision was made approximately 1 fingerbreadth above the pubic tubercle and in a skin crease.  dissection was taken down through the skin and subcutaneous tissue.  scarpa's fascia was divided, and the external ring was located.  the external oblique was divided from the external ring up towards the anterior superior iliac spine.  the cord structures were then encircled.  careful inspection of the cord structures did not reveal any indirect sac along the cord structures.  i did, however, feel a direct sac with a direct defect.  i opened the floor of the inguinal canal and dissected out the preperitoneal space at the direct sac and cut out the direct sac.  once i cleared out the preperitoneal space, i placed a phs mesh system with a posterior mesh into the preperitoneal space, and i made sure that it laid flat along cooper's ligament and covered the myopectineal orifice.  i then tucked the extended portion of the anterior mesh underneath the external oblique between the external oblique and the internal oblique, and i then tacked the medial portion of the mesh to the pubic tubercle with a 0 ethibond suture.  i tacked the superior portion of the mesh to the internal oblique and the inferior portion of the mesh to the shelving edge of the inguinal ligament.  i cut a hole in the mesh in order to incorporate the cord structures and recreated the internal ring, making sure that it was not too tight so that it did not strangulate the cord structures.  i then closed the external oblique with a running 3-0 vicryl.  i closed the scarpa's with interrupted 3-0 vicryl, and i closed the skin with a running monocril.  sponge, instrument and needle counts were correct at the end of the case.  the patient tolerated the procedure well and without any complications.",37
"multisystem exam,constitutional: , the vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  the patient appeared alert.,eyes: , the conjunctiva was clear.  the pupil was equal and reactive.  there was no ptosis.  the irides appeared normal.,ears, nose and throat: , the ears and the nose appeared normal in appearance.  hearing was grossly intact.  the oropharynx showed that the mucosa was moist.  there was no lesion that i could see in the palate, tongue. tonsil or posterior pharynx.,neck: , the neck was supple.  the thyroid gland was not enlarged by palpation.,respiratory:  ,the patient's respiratory effort was normal.  auscultation of the lung showed it to be clear with good air movement.,cardiovascular: , auscultation of the heart revealed s1 and s2 with regular rate with no murmur noted.  the extremities showed no edema.,breasts:  ,breast inspection showed them to be symmetrical with no nipple discharge.  palpation of the breasts and axilla revealed no obvious mass that i could appreciate.,gastrointestinal:  ,the abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  bowel sounds were present.,gu:  ,the external genitalia appeared to be normal.  the pelvic exam revealed no adnexal masses.  the uterus appeared to be normal in size and there was no cervical motion tenderness.,lymphatic:  ,there was no appreciated node that i could feel in the groin or neck area.,musculoskeletal:  ,the head and neck by inspection showed no obvious deformity.  again, the extremities showed no obvious deformity.  range of motion appeared to be normal for the upper and lower extremities.,skin:,  inspection of the skin and subcutaneous tissues appeared to be normal.  the skin was pink, warm and dry to touch.,neurologic: , deep tendon reflexes were symmetrical at the patellar area.  sensation was grossly intact by touch.,psychiatric:  ,the patient was oriented to time, place and person.  the patient's judgment and insight appeared to be normal.",4
"preoperative diagnosis: , squamous cell carcinoma on the right hand, incompletely excised.,postoperative diagnosis: , squamous cell carcinoma on the right hand, incompletely excised.,name of operation: , re-excision of squamous cell carcinoma site, right hand.,anesthesia:,  local with monitored anesthesia care.,indications:,  patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  the deep margin was positive.  other margins were clear.  he was brought back for re-excision.,procedure:,  the patient was brought to the operating room and placed in the supine position.  he was given intravenous sedation.  the right hand was prepped and draped in the usual sterile fashion.  three cubic centimeters of 1% xylocaine mixed 50/50 with 0.5% marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  the tissue was passed off the field as a specimen.,the wound was irrigated with warm normal saline.  hemostasis was assured with the electrocautery.  the wound was closed with running 3-0 nylon without complication.  the patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.",36
"chief complaint:,  leg pain.,history of present illness:,  this is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle.  she has noticed it since she has been on lipitor.  she has had some night sweats occasionally.  she has had a little bit of fever and nausea.  she has noticed her blood sugars have been low.  she has lost over 30 pounds after exercising doing water aerobics at genesis in wichita.  she has noticed her fasting blood sugars have been ranging from 100 to 120.  blood sugars one and a half hours after meals have been 185.  she is coming in for a diabetic checkup in one month and wants lab prior to that time.  she has been eating more meat recently and has not been on a diet for cholesterol.,current medications:,  include lipitor 80 mg q.d. discontinued today, vioxx 25 mg q.d., maxzide 37/25 q.d., protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., glucovance 1.25/250 b.i.d. decreased to one a day today, monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,allergies:,  cipro, sulfa, bactrim, and demerol.,objective:,vital signs:  weight is 248 pounds which is a 12-pound drop from january.  blood pressure 120/70.  pulse 68.,general:  this is a well-developed adult female, awake, alert, and in no acute distress.,heent:  oropharynx and heent are within normal limits.,lungs:  clear.,heart:  regular rhythm and rate.,abdomen:  soft, nontender, and nondistended without organomegaly.,gu:  palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,neurologic:  deep tendon reflexes are normal.,extremities:  pulses in lower extremities are normal.  straight leg lifts are normal.,assessment/plan:,1.  leg pain/bone pain, i am going to check her cmp.  i think this possibly is a side effect from lipitor.  we will stop lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time.  certainly if her pain improves might consider something like crestor, which is more water soluble, which may cause less adverse effects.  we will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2.  hypercholesterolemia, this is somewhat bothersome as she is a diabetic.  did discuss with her that we need to stick to the diet especially after going off of lipitor.  we will see how she does with her bone pain/leg pain off of lipitor.  if she has improvement may consider crestor in one month.  i am going to check her lipid panel and a cmp.  apparently, she is going to get this at a different site, mapleridge in wichita.,3.  type ii diabetes.  we will decrease her glucovance because she is having frequent low blood sugars.  her previous hemoglobin a1c was 5.6 so we will see if this improves her symptoms.  i am also going to check a hemoglobin a1c at mapleridge in wichita and have a followup here in one month for that diabetes appointment.",33
"preoperative diagnosis (es):,1. cholelithiasis.,2. cholecystitis.,postoperative diagnosis (es):,1. acute perforated gangrenous cholecystitis.,2. cholelithiasis.,procedure:,1. attempted laparoscopic cholecystectomy.,2. open cholecystectomy.,anesthesia:, general endotracheal anesthesia.,counts:, correct.,complications:, none apparent.,estimated blood loss:, 275 ml.,specimens:,1. gallbladder.,2. lymph node.,drains:, one 19-french round blake.,description of the operation:, after consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,after infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. dissecting further, the peritoneal cavity was entered. once this done, a hasson trocar was secured with #1 vicryl and the abdomen was insufflated without difficulty. a camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. a second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. a grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,the trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. the subcutaneous space was divided with electrocautery, as well as the muscles and fascia. the bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. an ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. after meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. after it was divided, the gallbladder was freed from the field.,once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. copious irrigation was also used. a 19-french blake drain was placed in morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-french round blake. once this was done, the umbilical port was closed with #1 vicryl in an interrupted fashion and then the wound was closed in two layers with #1 vicryl in an interrupted fashion. the skin was closed with and absorbable stitch.,the patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.",36
"preoperative diagnosis: , femoroacetabular impingement.,postoperative diagnosis: , femoroacetabular impingement.,operations performed,1.  left hip arthroscopic debridement.,2.  left hip arthroscopic femoral neck osteoplasty.,3.  left hip arthroscopic labral repair.,anesthesia: , general.,operation in detail: , the patient was taken to the operating room, where he underwent general anesthetic.  his bilateral lower extremities were placed under traction on the hana table.  his right leg was placed first.  the traction post was left line, and the left leg was placed in traction.  sterile hibiclens and alcohol prep and drape were then undertaken.  a fluoroscopic localization was undertaken.  gentle traction was applied.  narrow arthrographic effect was obtained.  following this, the protrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  the diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  for this reason, the acetabular articular cartilage was taken down and stabilized.  this necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  the labrum was repaired using absorbable smith & nephew anchors with a sliding smc knot.  after stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  the remnant articular surface of the femoral artery and acetabulum was stable.  the posterior leg was stable.  the traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  a stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  this terminated with the hip coming out of traction and indeterminable flexion.  a combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  the decompression was completed with thorough irrigation of the hip.  the cannula was removed, and the portals were closed using interrupted nylon.  the patient was placed into a sterile bandage and anesthetized intraarticularly with 10 ml of ropivacaine subcutaneously with 20 ml of ropivacaine and at this point was taken to the recovery room.  he tolerated the procedure very well with no signs of complications.",25
"chief complaint: , anxiety, alcohol abuse, and chest pain.,history of present illness:,  this is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  the patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  the patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  aggravated by breathing, coughing, and palpation over the area.  the pain was 9/10 in the emergency room and he was given some pain medications in the er and was basically admitted.  labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  the patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from anaheim memorial and then took 3 tablets together.  the patient has a history prior digoxin overdose of the same nature.,medications:,  digoxin 0.25 mg, metoprolol 50 mg, naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, klor-con 20 meq, advair diskus, questionable coreg.,past medical history: , mi in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  the last cardiologist he saw was dr. x and his primary doctor is dr. y.,social history:,  history of alcohol use in the past.,he is basically requesting for more and more pain medications.  he states that he likes dilaudid and would like to get the morphine changed to dilaudid.  his pain is tolerable.,physical examination:,vital signs:  stable.,general:  alert and oriented x3, no apparent distress.,heent:  extraocular muscles are intact.,cvs:  s1, s2 heard.,chest:  clear to auscultation bilaterally.,abdomen:  soft and nontender.,extremities:  no edema or clubbing.,neuro:  grossly intact.  tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,ekg basically shows atrial fibrillation, rate controlled, nonspecific st changes.,assessment and plan:,1.  this is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  now, he has had significant block with ekg changes as stated.  continue to follow the patient clinically at this time.  the patient has been admitted to icu and will be changed to dou.,2.  chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  the patient likely has opioid dependence and requesting more and more pain medications.  he is also bargaining for pain medications with me.  the patient was advised that he will develop more opioid dependence and i will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  the patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  we will try to verify his pain medications from his primary doctor and his pharmacy.  the patient said that he has been on dilaudid and vicodin es and norco and all these medications in the past.",4
"subjective complaints: ,constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. he also has pain and tightness in his low back increased on the left. his pain level is 7/10. he also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. he has also experienced anxiety and nervousness.,physical examination: ,height is 5'10"". weight is 270 pounds.,visual evaluation: the patient has anterior head carriage with rounded shoulders. he does not seem to be in any extreme distress. he has slight antalgic head position to the right.,dynamometer testing (grip strength) in pounds: the patient is right hand dominant. right hand 110, 105, and 98. left hand 80, 70, and 85.,neurological: sensation was normal in the upper and lower extremities. motor strength +5/5 bilaterally in the upper extremities. reflexes: upper extremities +2/2 bilaterally, lower extremities patellar +0/2 bilaterally, and s1 +2/2 bilaterally.,cervical spine range of motion:,flexion 50/50 with moderate discomfort on the left.,extension 50/60 with moderate discomfort on the left.,right lateral bending 40/45 with moderate discomfort on the left.,left lateral bending 40/45 with moderate discomfort on the right.,right rotation 70/80 with moderate pain in the left.,left rotation 70/80 with moderate pain in the left.,lumbosacral range of motion:,flexion 60/60.,extension 25/25.,right lateral bending 25/25.,left lateral bending 25/25 with pain in the left.,right rotation 30/30 with moderate discomfort in the right.,left rotation 30/30.,orthopedic tests: axial compression negative with moderate pain bilaterally. shoulder distraction negative with moderate pain bilaterally. maigne's test negative bilaterally. valsalva normal and swallow test normal. heel walk normal. toe walk normal. sitting root normal. slr normal. patrick-faber's normal. iliac compression caused moderate pain in the left.,radiology findings:, x-rays of the cervical and lumbar will be taken today.,diagnoses:,1.  cervical spine sprain/strain.,2.  lumbar spine sprain/strain.,3.  tension headaches.,causation:  ,the patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. his history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. the patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.,prognosis: ,the likelihood of nearly complete symptomatic relief within 90 days is excellent.  the patient should reach maximum medical improvement in three or four months.,treatment/plan: ,after completing an initial examination evaluation, i have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. i feel it is too early to determine whether this patient will have any residuals or permanent disability.",3
"preoperative diagnosis: , acute acalculous cholecystitis.,postoperative diagnosis:,  acute hemorrhagic cholecystitis.,procedure performed: , open cholecystectomy.,anesthesia: , epidural with local.,complications: , none.,disposition: , the patient tolerated the procedure well and was transferred to recovery in stable condition.,specimen:  ,gallbladder.,brief history:  ,the patient is a 73-year-old female who presented to abcd general hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture.  the patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the orthopedics department.  subsequently, the patient was doing well postoperatively, however, the patient does have severe o2 and steroid-dependent copd and at an extreme risk for any procedure.  the patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain.  during the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder.  the patient did well postdrainage.  the patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp.  however, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003.  a hida scan had been performed, which showed no cystic duct obstruction.  a tube cholecystogram was performed, which showed no cystic or common duct obstruction.  there was abnormal appearance of the gallbladder, however, the pathway was patent.  thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy.  initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe copd and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,intraoperative findings:  ,the patient's gallbladder had some patchy and necrosis areas.  there were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.  the patient also had no plane between the gallbladder and the liver bed.,operative procedure: , after informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family.  the patient was brought to the operating room after an epidural was performed per anesthesia.  local anesthesia was given with 1% lidocaine.  a paramedian incision was made approximately 5 cm in length with a #15 blade scalpel.  next, hemostasis was obtained using electro bovie cautery.  dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel.  next, metzenbaum scissors were used to extend the incision and the abdomen was entered .  the gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view.  dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified.  the cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with metzenbaum scissors.  the cystic duct was identified.  a silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a metzenbaum scissors.  the gallbladder was then removed from the liver bed using electro bovie cautery.  a plane was created.  the hemostasis was obtained using the electro bovie cautery as well as some surgicel.  the gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections.  permanent sections are still pending.  the remainder of the fossa was hemostatic with the surgicel and attention was next made to closing the abdomen.  the peritoneum as well as posterior rectus fascia was approximated with a running #0 vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 vicryl sutures.  skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.",36
"preoperative diagnoses,1.  intrauterine pregnancy at 39 plus weeks gestation.,2.  gestational hypertension.,3.  thick meconium.,4.  failed vacuum attempted delivery.,postoperative diagnoses,1.  intrauterine pregnancy at 39 plus weeks gestation.,2.  gestational hypertension.,3.  thick meconium.,4.  failed vacuum attempted delivery.,operation performed: , spontaneous vaginal delivery.,anesthesia: , epidural was placed x2.,estimated blood loss:,  500 ml.,complications: , thick meconium.  severe variables, apgars were 2 and 7.  respiratory therapy and icn nurse at delivery.  baby went to newborn nursery.,findings: , male infant, cephalic presentation, roa.  apgars 2 and 7.  weight 8 pounds and 1 ounce.  intact placenta.  three-vessel cord.  third degree midline tear.,description of operation: , the patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  she was already 3 cm dilated.  she had artificial rupture of membranes.  pitocin was started and she actually went to complete dilation.  while pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  when she was complete +2, vacuum attempted delivery, three pop-offs were done.  the vacuum was then no longer used after the three pop-offs.  the patient pushed for a little bit longer and had a delivery, roa, of a male infant, cephalic, over a third-degree midline tear.  secondary to the thick meconium, delee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  baby was delivered floppy.  cord was clamped x2 and cut, and the baby was handed off to awaiting icn nurse and respiratory therapist.  delivery of intact placenta and three-vessel cord.  third-degree midline tear was repaired with vicryl without any complications.  baby initially did well and went to newborn nursery, where they are observing him a little bit longer there.  again, mother and baby are both doing well.  mother will go to postpartum and baby is already in newborn nursery.",22
"reason for consultation:,  ventricular ectopy and coronary artery disease.,history of present illness:  ,i am seeing the patient upon the request of dr. y.  the patient is a very well known to me.  he is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  the patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  the patient was admitted and being treated for pneumonia, according to him.  the patient denies any chest pain, chest pressure, or heaviness.  denies any palpitations, fluttering, or awareness of heart activity.  however, on monitor, he was noticed to have pvcs random.  he had run off three beats consecutive one time at 12:46 p.m. today.  the patient denied any awareness of that or syncope.,review of systems:,constitutional:  no fever or chills.,eyes:  no visual disturbances.,ent:  no difficulty swallowing.,cardiovascular:  prior history of chest discomfort in 08/2009 with negative stress study.,respiratory:  cough and shortness of breath.,musculoskeletal:  positive for arthritis and neck pain.,gu:  unremarkable.,neurologic:  otherwise unremarkable.,endocrine:  otherwise unremarkable.,hematologic:  otherwise unremarkable.,allergic:  otherwise unremarkable.,past medical history:,1.  positive for coronary artery disease since 2002.,2.  history of peripheral vascular disease for over 10 years.,3.  copd.,4.  hypertension.,past surgical history:,  right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,medications at home:,1.  aspirin 81 mg daily.,2.  clopidogrel 75 mg daily.,3.  allopurinol 100 mg daily.,4.  levothyroxine 100 mcg a day.,5.  lisinopril 10 mg a day.,6.  metoprolol 25 mg a day.,7.  atorvastatin 10 mg daily.,allergies: , the patient does have allergy to medication.  he said he cannot take aspirin because of intolerance for his stomach and stomach upset, but no true allergy to aspirin.,family history:,  no history of premature coronary artery disease.  one daughter has early onset diabetes and one child has asthma.,social history: , he is married and retired.  he has nine children, 25 grandchildren.  he smokes one pack per day.  he smoked 50 pack years and had no intention of quitting according to him.,physical examination:,vital signs:  temperature of 97, heart rate of 90, blood pressure of 187/105.,heent:  normocephalic and atraumatic.  no thyromegaly or lymphadenopathy.,neck:  supple.,cardiovascular:  upstroke is normal.  distal pulse symmetrical.  heart regular with a normal s1 with normally split s2.  there is an s4 at the apex.,lungs:  with decreased air entry.  no wheezes.,abdominal:  benign.  no masses.,extremities:  no edema, cyanosis, or clubbing.,neurologic:  awake, alert, and oriented x3.  no focal deficits.,imaging studies: , echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, ef of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.",4
"reason for admission: , sepsis.,history of present illness:  ,the patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  in the emergency room, the patient was found to have a ct scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  the patient is unable to provide further history.  the patient's son is at the bedside and confirmed his history.  the patient was given iv antibiotics in the emergency room.  he was also given some hydration.,past medical history:,1.  history of cad.,2.  history of dementia.,3.  history of cva.,4.  history of nephrolithiasis.,allergies: , none.,medications:,1.  ambien.,2.  milk of magnesia.,3.  tylenol.,4.  tramadol.,5.  soma.,6.  coumadin.,7.  zoloft.,8.  allopurinol.,9.  digoxin.,10.  namenda.,11.  zocor.,12.  buspar.,13.  detrol.,14.  coreg.,15.  colace.,16.  calcium.,17.  zantac.,18.  lasix.,19.  seroquel.,20.  aldactone.,21.  amoxicillin.,family history:  ,noncontributory.,social history: , the patient lives in a board and care.  no tobacco, alcohol or iv drug use.,review of systems: , as per the history of present illness, otherwise unremarkable.,physical examination:,vital signs:  the patient is currently afebrile.  pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,general:  the patient is awake.  not oriented x3, in no acute distress.,heent:  pupils are equal, round, and reactive to light and accommodation.  extraocular movements are intact.  mucous membranes are dry.,neck:  supple.  no thyromegaly.  no jugular venous distention.,heart:  irregularly irregular, brady.,lungs:  clear to auscultation bilaterally anteriorly.,abdomen:  positive normoactive bowel sounds.  soft.  tenderness in the suprapubic region without rebound.,extremities:  no clubbing, cyanosis or edema in upper and lower extremities.",14
"procedure: , colonoscopy.,preoperative diagnoses:,  the patient is a 56-year-old female.  she was referred for a screening colonoscopy.  the patient has bowel movements every other day.  there is no blood in the stool, no abdominal pain.  she has hypertension, dyslipidemia, and gastroesophageal reflux disease.  she has had cesarean section twice in the past.  physical examination is unremarkable.  there is no family history of colon cancer.,postoperative diagnosis: , diverticulosis.,procedure in detail: , procedure and possible complications were explained to the patient.  ample opportunity was provided to her to ask questions.  informed consent was obtained.  she was placed in left lateral position.  inspection of perianal area was normal.  digital exam of the rectum was normal.,video olympus colonoscope was introduced into the rectum.  the sigmoid colon is very tortuous.  the instrument was advanced to the cecum after placing the patient in a supine position.  the patient was well prepared and a good examination was possible.  the cecum was identified by the ileocecal valve and the appendiceal orifice.  images were taken.  the instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  few diverticula were encountered in the sigmoid and descending colon.  retroflex view of the rectum was unremarkable.  no polyps or malignancy was identified.,after obtaining images, the air was suctioned.  instrument was withdrawn from the patient.  the patient tolerated the procedure well.  there were no complications.,summary of findings:  ,colonoscopy was performed to cecum and demonstrates the following:,1.  mild-to-moderate diverticulosis.,2.  ,recommendation:,1.  the patient was provided information on diverticulosis including dietary advice.,2.  she was advised repeat colonoscopy after 10 years.",36
"cc: ,rle weakness.,hx: ,this 42y/o rhm was found 2/27/95 slumped over the steering wheel of the fed ex truck he was driving. he was cyanotic and pulseless according to witnesses. emt evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. upon arrival at a local er his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. this had no effect. he was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. he was then taken emergently to cardiac catherization and was found to have normal coronary arteries. he was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. his blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. recovery was complicated by acute renal failure and liver failure. initail ck=13,780, the ckmb fraction was normal at 0.8.,on 3/10/95, the patient experienced cp and underwent cardiac catherization. this time he was found to have a single occlusion in the distal lad with association inferior hypokinesis. subsequent ck=1381 and ckmb=5.4 (elevated). the patient was amnestic to the event and for 10 days following the event. he was transferred to uihc for cardiac electrophysiology study.,meds: ,nifedipine, asa, amiodarone, capoten, isordil, tylenol, darvocet prn, reglan prn, coumadin, kcl, slntg prn, caco3, valium prn, nubain prn.,pmh:, hypercholesterolemia.,fhx:, father alive age 69 with h/o tias. mother died age 62 and had chf, a-fib, cad. maternal grandfather died of an mi and had h/o svt. maternal grandmother had h/o svt.,shx: ,married, 7 children, driver for fed ex. denied tobacco/etoh/illicit drug use.,exam: ,bp112/74 hr64 rr16 afebrile.,ms: a&o to person, place and time. euthymic with appropriate affect.,cn: unremarkable.,motor: hip flexion 3/5, hip extension 5/5, knee flexion5/5, knee extension 2/5, plantar flexion, extension, inversion and eversion 5/5. there was full strength thoughout bue.,sensory: decreased pp/vib/lt/temp about anterior aspect of thigh and leg in a femoral nerve distribution.,coord: poor and slowed hks on right due to weakness.,station: no drift or romberg sign.,gait: difficulty bearing weight on rle.,reflexes: 1+/1+ throughout bue. 0/2 patellae. 2/2 archilles. plantar responses were flexor, bilaterally.,course:, mri pelvis, 3/28/95, revealed increased t1 weighted signal within the right iliopsoas suggestive of hematoma. an intra-osseous lipoma was incidentally notice in the right sacrum. neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. these findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. he underwent implantation of a medtronic internal cardiac difibrillator. his cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. he suffered mild to moderate permanent rle weakness, especially involving the quadriceps. his femoral nerve compression had been present to long to warrant decompression. emg/ncv studies revealed severe axonal degeneration.",20
"preoperative diagnoses:,1.  mass, left second toe.,2.  tumor.,3.  left hallux bone invasion of the distal phalanx.,postoperative diagnoses:,1.  mass, left second toe.,2.  tumor.,3.  left hallux with bone invasion of the distal phalanx.,procedure performed:,1.  excision of mass, left second toe.,2.  distal syme's amputation, left hallux with excisional biopsy.,history: , this 47-year-old caucasian male presents to abcd general hospital with a history of tissue mass on his left foot.  the patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  the patient also has history of shave biopsy in the past.  the patient does state that he desires surgical excision at this time.,procedure in detail:,  an iv was instituted by the department of anesthesia in the preoperative holding area.  the patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  copious amount of webril was placed around the left ankle followed by a blood pressure cuff.  after adequate sedation by the department of anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,the foot was then prepped and draped in the usual sterile orthopedic fashion.  the foot was elevated from the operating table and exsanguinated with an esmarch bandage.  care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  the foot was lowered to the operating table.  the stockinet was reflected and the foot was cleansed with wet and dry sponge.  a distal syme's incision was planned over the distal aspect of the left hallux.  the incision was performed with a #10 blade and deepened with #15 down to the level of bone.  the dorsal skin flap was removed and dissected in toto off of the distal phalanx.  there was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  the tissue was sent to pathology where dr. green stated that a frozen sample would be of less use for examining for cancer.  dr. green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  at this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  the area was inspected for any remaining suspicious tissues.  any suspicious tissue was removed.  the area was then flushed with copious amounts of sterile saline.  the skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,attention was then directed to the left second toe.  there was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  a linear incision was made just medial to the tissue mass.  the mass was then dissected from the overlying skin and off of the underlying capsule.  this tissue mass was hard, round, and pearly-gray in appearance.  it does not invade into any other surrounding tissues.  the area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  dressings consisted of owen silk soaked in betadine, 4x4s, kling, kerlix, and an ace wrap.  the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  the patient tolerated the above procedure and anesthesia well without complications.  the patient was transported to pacu with vital signs stable and vascular status intact.  the patient was given postoperative pain prescription for vicodin and instructed to follow up with dr. bonnani in his office as directed.  the patient will be contacted immediately pending the results of pathology.  cultures obtained in the case were aerobic and anaerobic gram stain, silver stain, and a cbc.",29
"preoperative diagnosis: , t12 compression fracture with cauda equina syndrome and spinal cord compression.,postoperative diagnosis:,  t12 compression fracture with cauda equina syndrome and spinal cord compression.,operation performed: , decompressive laminectomy at t12 with bilateral facetectomies, decompression of t11 and t12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink synthes click'x system using 6.5 mm diameter x 40 mm length t11 screws and l1 screws, 7 mm diameter x 45 mm length.,anesthesia: , general endotracheal.,estimated blood loss:,  400 ml, replaced 2 units of packed cells.,preoperative hemoglobin was less than 10.,drains:,  none.,complications:,  none.,description of procedure: , with the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the t12-l1 interspace.  an incision was made over the posterior spinous process of t10, t11, t12, l1, and l2.  a weitlaner retractor was placed and cutting bovie current was used to incise the fascia overlying the dorsal spinous process of t10, t11, t12, l1, and l2.  an additional muscular ligamentous attachment was dissected free bilaterally with cutting bovie current osteotome and cobb elevator.  the cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at t12 was apparent.  initially, on the patient's left side, pedicle screws were placed in t11 and l1.  the inferior articular facet was removed at t11 and an awl placed at the proximal location of the pedicle.  placement confirmed with biplanar coaxial fluoroscopy.  the awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of t11.  a 40-mm click'x screw, 6.5 mm diameter with rod holder was then threaded into the t11 vertebral body.,attention was next turned to the l1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an am-8 dissecting tool, am attachment to the midas rex instrumentation.  the area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in l1.  using a pedicle probe, the pedicle was then probed to the mid body of l1 and a 7-mm diameter 45-mm in length click'x synthes screw with rod holder was placed in the l1 vertebral body.,at this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the mri findings of significant compression on the patient's ventral canal on the right side.  attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at t12 was noted be completely disrupted on a traumatic basis.  the anteroposterior spinous process ligament superior to the t12 was incised with cutting bovie current and the posterior spinous process at t12 removed with a leksell rongeur.  it was necessary to remove portion of the posterior spinous process at t11 for a full visualization of the involved laminar fractures at t12.,at this point, a laminectomy was performed using 45-degree kerrison rongeur, both 2 mm and 4 mm, and leksell rongeur.  there was an epidural hematoma encountered to the midline and left side at the mid portion of the t12 laminectomy and this was extending superiorly to the t11-t12 interlaminar space.  additionally, there was marked instability of the facets bilaterally at t12 and l1.  these facets were removed with 45-degree kerrison rongeur and leksell rongeur.  bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree kerrison rongeur until the thecal sac was completely decompressed.  the exiting nerve roots at t11 and t12 were visualized and followed with frazier dissectors, and these nerve roots were noted to be completely free.  hemostasis was controlled with bipolar coagulation.,at this point, a frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the t11-t12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  a #4 penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at t11 and l1 using the technique described for a left-sided pedicle screw placement.  the anatomic landmarks being the transverse process at t11, the inferior articulating facet, and the lateral aspect of the superior articular facet for t11 and at l1, the transverse process, the junction of the intra-articular process and the facet joint.,with the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  it was felt that distraction was not necessary.  a 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  the locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at t11-t12 or t12-l1 with excellent positioning of the rods and screws.  a crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,it should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at t11, t12, and l1 with am-8 dissecting tool, am attachment as well as the lateral aspects of the facet joints.  this was done bilaterally prior to placement of the rods.,following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 vicryl suture.  the fascia was closed with interrupted 0 vicryl suture, subcutaneous layer was closed with 2-0 vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted vicryl suture, and the skin approximated with staples.  the patient appeared to tolerate the procedure well without complications.",21
"procedures performed: , phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,procedure codes: , 64640 times one, 64614 times two, 95873 times two.,preoperative diagnosis: , spastic right hemiparetic cerebral palsy, 343.1.,postoperative diagnosis:,  spastic right hemiparetic cerebral palsy, 343.1.,anesthesia:,  mac.,complications: , none.,description of technique: , informed consent was obtained from the patient.  she was brought to the minor procedure area and sedated per their protocol.  the patient was positioned lying supine.  skin overlying all areas injected was prepped with chlorhexidine.  the right obturator nerve was identified using active emg stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  approximately 6 ml of 5% phenol was injected in this location.  at all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  negative drawback for blood was done prior to each injection of phenol.,muscles injected with botulinum toxin were identified with active emg stimulation.  approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  total amount of botulinum toxin injected was 200 units diluted 25 units to 1 ml.  the patient tolerated the procedure well and no complications were encountered.",21
"preoperative diagnosis: , morbid obesity.,postoperative diagnosis:  ,morbid obesity.,procedure: , laparoscopic antecolic antegastric roux-en-y gastric bypass with eea anastomosis.,anesthesia: , general with endotracheal intubation.,indication for procedure: , this is a 30-year-old female, who has been overweight for many years.  she has tried many different diets, but is unsuccessful.  she has been to our bariatric surgery seminar, received some handouts, and signed the consent.  the risks and benefits of the procedure have been explained to the patient.,procedure in detail:  ,the patient was taken to the operating room and placed supine on the operating room table.  all pressure points were carefully padded.  she was given general anesthesia with endotracheal intubation.  scd stockings were placed on both legs.  foley catheter was placed for bladder decompression.  the abdomen was then prepped and draped in standard sterile surgical fashion.  marcaine was then injected through umbilicus.  a small incision was made.  a veress needle was introduced into the abdomen.  co2 insufflation was done to a maximum pressure of 15 mmhg.  a 12-mm versastep port was placed through the umbilicus.  i then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  i placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, i placed a 12-mm versastep port.  on the left side, just anterior to the midaxillary line and just subcostal, i placed a 5-mm port.  a few centimeters below and medial to that, i placed a 15-mm port.  i began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of treitz.  i ran the small bowel down approximately 40 cm and divided the small bowel with a white load gia stapler.  i then divided the mesentery all the way down to the base of the mesentery with a ligasure device.  i then ran the distal bowel down, approximately 100 cm, and at 100 cm, i made a hole at the antimesenteric portion of the roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and i passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  i reapproximated the edges of the defect.  i lifted it up and stapled across it with another white load stapler.  i then closed the mesenteric defect with interrupted surgidac sutures.  i divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  i then put the patient in reverse trendelenburg.  i placed a liver retractor, identified, and dissected the angle of his.  i then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  i fired transversely across the stomach with a 45 blue load stapler.  i then used two fires of the 60 blue load with seamguard to go up into my angle of his, thereby creating my gastric pouch.  i then made a hole at the base of the gastric pouch and had anesthesia remove the bougie and place the og tube connected to the anvil.  i pulled the anvil into place, and i then opened up my 15-mm port site and passed my eea stapler.  i passed that in the end of my roux limb and had the spike come out antimesenteric.  i joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my roux limb with a white load gi stapler, and removed it with an endocatch bag.  i put some additional 2-0 vicryl sutures in the anastomosis for further security.  i then placed a bowel clamp across the bowel.  i went above and passed an egd scope into the mouth down to the esophagus and into the gastric pouch.  i distended gastric pouch with air.  there was no air leak seen.  i could pass the scope easily through the anastomosis.  there was no bleeding seen through the scope.  we closed the 15-mm port site with interrupted 0 vicryl suture utilizing carter-thomason.  i copiously irrigated out that incision with about 2 l of saline.  i then closed the skin of all incisions with running monocryl.  sponge, instrument, and needle counts were correct at the end of the case.  the patient tolerated the procedure well without any complications.",1
"indication: , chest pain.,type of test: , adenosine with nuclear scan as the patient unable to walk on a treadmill.,interpretation:, resting heart rate of 67, blood pressure of 129/86.  ekg, normal sinus rhythm.  post-lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  ekg remained the same.  no symptoms were noted.,summary:,1.  nondiagnostic adenosine stress test.,2.  nuclear interpretation as below.,nuclear interpretation:,  resting and stress images were obtained with 10.4, 33.1 mci of tetrofosmin injected intravenously by standard protocol.  nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  gated spect revealed normal wall motion, ejection fraction of 58%.  end-diastolic volume of 74, end-systolic volume of 31.,impression:,1.  normal nuclear myocardial perfusion scan.,2.  ejection fraction 58% by gated spect.",2
"chief complaint:,  multiple problems, main one is chest pain at night.,history of present illness:,  this is a 60-year-old female with multiple problems as numbered below:,1.  she reports that she has chest pain at night.  this happened last year exactly the same.  she went to see dr. murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month.  she wakes in the middle of the night and reports that she has a pressure.  it is mild-to-moderate in the middle of her chest and will stay there as long she lies down.  if she gets up, it goes away within 15 minutes.  it is currently been gone on for the last week.  she denies any fast heartbeats or irregular heartbeats at this time.,2.  she has been having stomach pains that started about a month ago.  this occurs during the daytime.  it has no relationship to foods.  it is mild in nature, located in the mid epigastric area.  it has been better for one week as well.,3.  she continues to have reflux, has noticed that if she stops taking aciphex, then she has symptoms.  if she takes her aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4.  she has right flank pain when she lies down.  she has had this off and on for four months.  it is a dull achy pain.  it is mild in nature.,5.  she has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past.  it is not painful.,6.  she has had spots in her armpits initially on the right side and then going to the left side.  they are not itchy.,7.  she is having problems with urgency of urine.  when she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking.  she is wearing a pad now.,8.  she is requesting a colonoscopy for screening as well.  she is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9.  she has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months.  there has been no swelling or redness or trauma to these areas.,review of systems:,  she has recently been to the eye doctor.  she has noticed some hearing loss gradually.  she denies any problems with swallowing.  she denies episodes of shortness of breath, although she has had a little bit of chronic cough.  she has had normal bowel movements.  denies any black or bloody stools, diarrhea, or constipation.  denies seeing blood in her urine and has had no urinary problems other than what is stated above.  she has had no problems with edema or lower extremity numbness or tingling.,social history:,  she works at nursing home.  she is a nonsmoker.  she is currently trying to lose weight.  she is on the diet and has lost several pounds in the last several months.  she quit smoking in 1972.,family history: , her father has type i diabetes and heart disease.  she has a brother who had heart attack at the age of 52.  he is a smoker.,past medical history:,  episodic leukopenia and mild irritable bowel syndrome.,current medications:,  aciphex 20 mg q.d. and aspirin 81 mg q.d.,allergies:,  no known medical allergies.,objective:,vital signs:  weight:  142 pounds.  blood pressure:  132/78.  pulse:  72.,general:  this is a well-developed adult female who is awake, alert, and in no acute distress.,heent:  her pupils are equally round and reactive to light.  conjunctivae are white.  tms look normal bilaterally.  oropharynx appears to be normal.  dentition is excellent.,neck:  supple without lymphadenopathy or thyromegaly.,lungs:  clear with normal respiratory effort.,heart:  regular rhythm and rate without murmur.  radial pulses are normal bilaterally.,abdomen:  soft, nontender, and nondistended without organomegaly.,extremities:  examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the pip joint and dip joint.  her armpits are examined.  she has what appears to be a tinea versicolor rash present in the armpits bilaterally.  she has a lesion on her left shoulder, which is 6 mm in diameter.  it has diffuse borders and is slightly red.  it has two brown spots in it.  in her lower extremities, there is no cyanosis or edema.  pulses at the radial and posterior tibial pulses are normal bilaterally.  her gait is normal.,psychiatric:  her affect is pleasant and positive.,neurological:  she is grossly intact.  her speech seems to be clear.  her coordination of upper and lower extremities is normal.,assessment/plan:,1.  chest pain.  at this point, because of dr. murphy’s evaluation last year and the symptoms exactly the same, i think this is noncardiac.  my intonation is that this is reflux.  i am going have her double her aciphex or increase it to b.i.d., and i am going to have her see dr. xyz for possible egd if he thinks that would be appropriate.  she is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2.  stomach pain, uncertain at this point, but i feel like this is probably related as well to chest pain.,3.  suspicious lesions on the left shoulder.  we will do a punch biopsy and set her up for an appointment for that.,4.  tinea versicolor in the axillary area.  i have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5.  cystocele.  we will have her see dr. xyz for further discussion of repair due to her urinary incontinence.,6.  history of leukopenia.  we will check a cbc.,7.  pain in the thumbs, probably arthritic in nature, observe for now.,8.  screening.  we will have her see dr. xyz for discussion of colon cancer screening.,9.  gastroesophageal reflux disease.  i have increased aciphex to b.i.d. for now.",14
"preoperative diagnoses: , cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion.,postoperative diagnoses: , cervical spondylosis, status post complex anterior cervical discectomy, corpectomy, decompression and fusion, and potentially unstable cervical spine.,operative procedure:  ,application of pmt large halo crown and vest.,estimated blood loss: , none.,anesthesia:  ,local, conscious sedation with morphine and versed.,complications: , none.  post-fixation x-rays, nonalignment, no new changes.  post-fixation neurologic examination normal.,clinical history:  ,the patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy.  she was referred to me by dr. x.  the patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate.  surgery had gone well, and the patient has done well in the last 2 days.  she is neurologically improved and is moving all four extremities.  no airway issues.  it was felt that the patient was now a candidate for a halo vest placement given that chance of going to the or were much smaller.  she was consented for the procedure, and i sought the help of abc and felt that a pmt halo would be preferable to a bremer halo vest.  the patient had this procedure done at the bedside, in the sicu room #1.  i used a combination of some morphine 1 mg and versed 2 mg for this procedure.  i also used local anesthetic, with 1% xylocaine and epinephrine a total of 15 to 20 cc.,procedure details:,  the patient's head was positioned on some towels, the retroauricular region was shaved, and the forehead and the posterolateral periauricular regions were prepped with betadine.  a large pmt crown was brought in and fixed to the skull with pins under local anesthetic.  excellent fixation achieved.  it was lateral to the supraorbital nerves and 1 fingerbreadth above the brows and the ear pinnae.,i then put the vest on, by sitting the patient up, stabilizing her neck.  the vest was brought in from the front as well and connected.  head was tilted appropriately, slightly extended, and in the midline.  all connections were secured and pins were torqued and tightened.,during the procedure, the patient did fine with no significant pain.,post-procedure, she is neurologically intact and she remained intact throughout.  x-rays of the cervical spine ap, lateral, and swimmer views showed excellent alignment of the hardware construct in the graft with no new changes.,the patient will be subjected to a ct scan to further define the alignment, and barring any problems, she will be ambulating with the halo on.,the patient will undergo pin site care as per protocol, and likely she will go in the next 2 to 3 days.  her prognosis indeed is excellent, and she is already about 90% or so better from her surgery.  she is also on a short course of decadron, which we will wean off in due course.,the matter was discussed with the patient and the patient's family.",21
"preoperative diagnosis: , right hand dupuytren disease to the little finger.,postoperative diagnosis:  ,right hand dupuytren disease to the little finger.,procedure performed:  ,excision of dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,complications:  ,none.,blood loss: , minimal.,anesthesia: , bier block.,indications:  ,the patient is a 51-year-old male with left dupuytren disease, which is causing contractions both at the metacarpophalangeal and the pip joint as well as significant discomfort.,description of procedure:  ,the patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  a zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  skin flaps were elevated carefully, dissecting dupuytren contracture off the undersurface of the flaps.  both neurovascular bundles were identified proximally in the hand and the dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  the neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the pip joint of the finger where the dupuytren disease stopped.  the wound was irrigated.  the neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the dupuytren disease.  the incisions were closed with 5-0 nylon interrupted sutures.,the patient tolerated the procedure well and was taken to the pacu in good condition.",25
"indications for procedure: , a 79-year-old filipino woman referred for colonoscopy secondary to heme-positive stools.  procedure done to rule out generalized diverticular change, colitis, and neoplasia.,description of procedure: , the patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  informed consent was signed by the patient.,with the patient in left decubitus position, had received a cumulative dose of 4 mg of versed and 75 mg of demerol, using olympus video colonoscope under direct visualization was advanced to the cecum.  photodocumentation of appendiceal orifice and the ileocecal valve obtained.  cecum was slightly obscured with stool but the colon itself was adequately prepped.  there was no evidence of overt colitis, telangiectasia, or overt neoplasia.  there was moderately severe diverticular change, which was present throughout the colon and photodocumented.  the rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  the patient tolerated the procedure well without any complications.,impression:,1.  colonoscopy to the cecum with adequate preparation.,2.  long tortuous spastic colon.,3.  moderately severe diverticular changes present throughout.,4.  mild internal hemorrhoids.,recommendations:,1.  clear liquid diet today.,2.  follow up with primary care physician as scheduled from time to time.,3.  increase fiber in diet, strongly consider fiber supplementation.",36
"subjective: , the patient states she is feeling a bit better.,objective:,vital signs:  temperature is 95.4.  highest temperature recorded over the past 24 hours is 102.1.,chest:  examination of the chest is clear to auscultation.,cardiovascular:  first and second heart sounds were heard.  no murmurs appreciated.,abdomen:  benign.  right renal angle is tender.  bowel sounds are positive.,extremities:  there is no swelling.,neurologic:  the patient is alert and oriented x3.  examination is nonfocal.,laboratory data: , white count is down from 35,000 to 15.5.  hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  bun is down to 22, creatinine is within normal limits.,assessment and plan:,1.  sepsis due to urinary tract infection.  urine culture shows escherichia coli, resistant to levaquin.  we changed to doripenem.,2.  urinary tract infection, we will treat with doripenem, change foley catheter,3.  hypotension.  resolved, continue intravenous fluids.,4.  ischemic cardiomyopathy.  no evidence of decompensation, we with monitor.,5.  diabetes type 2.  uncontrolled.  continue insulin sliding scale.,6.  recent pulmonary embolism, inr is above therapeutic range, coumadin is on hold, we will monitor.,7.  history of coronary artery disease.  troponin indeterminate.  cardiologist intends no further workup.  continue medical treatment.  most likely troponin is secondary to impaired clearance.",33
"postoperative diagnosis:,  mild tracheobronchitis with history of granulomatous disease and tb, rule out active tb/miliary tb.,procedure performed:,  flexible fiberoptic bronchoscopy diagnostic with:,a.  right middle lobe bronchoalveolar lavage.,b.  right upper lobe bronchoalveolar lavage.,c.  right lower lobe transbronchial biopsies.,complications:,  none.,samples include bronchoalveolar lavage of the right upper lobe and right middle lobe and transbronchial biopsies of the right lower lobe.,indication:  ,the patient with a history of tb and caseating granulomata on open lung biopsy with evidence of interstitial lung disease and question tuberculosis.,procedure:,  after obtaining an informed consent, the patient was brought to the bronchoscopy suite with appropriate isolation related to ______ precautions.  the patient had appropriate oxygen, blood pressure, heart rate, and respiratory rate monitoring applied and monitored continuously throughout the procedure.  2 liters of oxygen via nasal cannula was applied to the nasopharynx with 100% saturations achieved.  topical anesthesia with 10 cc of 4% xylocaine was applied to the right nares and oropharynx.  subsequent to this, the patient was premedicated with 50 mg of demerol and then versed 1 mg sequentially for a total of 2 mg.  with this, adequate consciousness sedation was achieved.  3 cc of 4% viscous xylocaine was applied to the right nares.  the bronchoscope was then advanced through the right nares into the nasopharynx and oropharynx.,the oropharynx and larynx were well visualized and showed mild erythema, mild edema, otherwise negative.,there was normal vocal cord motion without masses or lesions.  additional topical anesthesia with 2% xylocaine was applied to the larynx and subsequently throughout the tracheobronchial tree for a total of 18 cc.  the bronchoscope was then advanced through the larynx into the trachea.  the trachea showed mild evidence of erythema and moderate amounts of clear frothy secretions.  these were suctioned clear.  the bronchoscope was then advanced through the carina, which was sharp.  then advanced into the left main stem and each segment, subsegement in the left upper lingula and lower lobe was visualized.  there was mild tracheobronchitis with mild friability throughout.  there was modest amounts of white secretion.  there were no other findings including evidence of mass, anatomic distortions, or hemorrhage.  the bronchoscope was subsequently withdrawn and advanced into the right mainstem.  again, each segment and subsegment was well visualized.  the right upper lobe anatomy showed some segmental distortion with dilation and irregularities both at the apical region as well as in the subsegments of the anteroapical and posterior segments.  no specific masses or other lesions were identified throughout the tracheobronchial tree on the right.  there was mild tracheal bronchitis with friability.  upon coughing, there was punctate hemorrhage.  the bronchoscope was then advanced through the bronchus intermedius and the right middle lobe and right lower lobe.  these again had no other anatomic lesions identified.  the bronchoscope was then wedged in the right middle lobe and bronchoalveolar samples were obtained.  the bronchoscope was withdrawn and the area was suctioned clear.  the bronchoscope was then advanced into the apical segment of the right upper lobe and the bronchioalveolar lavage again performed.  samples were taken and the bronchoscope was removed suctioned the area clear.  the bronchoscope was then re-advanced into the right lower lobe and multiple transbronchial biopsies were taken under fluoroscopic guidance in the posterior and lateral segments of the right lower lobe.  minimal hemorrhage was identified and suctioned clear without difficulty.  the bronchoscope was then withdrawn to the mainstem.  the area was suctioned clear.  fluoroscopy revealed no evidence of pneumothorax.  the bronchoscope was then withdrawn.  the patient tolerated the procedure well without evidence of desaturation or complications.",36
"history of present illness:,  ms. a is a 55-year-old female who presented to the bariatric surgery service for consideration of laparoscopic roux-en-y gastric bypass.  the patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including weight watchers, nutrisystem, jenny craig, tops, cabbage diet, grape fruit diet, slim-fast, richard simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  at the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  she has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,past medical history:,  significant for hypertension, for which the patient takes norvasc and lopressor for.  she also suffers from high cholesterol and is on lovastatin for this.  she has depression, for which she takes citalopram.  she also stated that she had a dvt in the past prior to her hysterectomy.  she also suffers from thyroid disease in the past though this is unclear, the nature of this.,past surgical history: , significant for cholecystectomy in 2008 for gallstones.  she also had a hysterectomy in 1994 secondary to hemorrhage.  the patient denies any other abdominal surgeries.,medications: , norvasc 10 mg p.o. daily, lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin d, premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin d 50,000 units q. weekly.,allergies: , the patient denies allergies to medications and to latex.,social history: , the patient is a homemaker.  she is married, with 2 children aged 22 and 28.  she is a lifelong nonsmoker and nondrinker.,family history:  ,significant for high blood pressure and diabetes as well as cancer on her father side.  he did pass away from congestive heart failure.  mother suffers from high blood pressure, cancer, and diabetes.  her mother has passed away secondary to cancer.  she has two brothers one passed away from brain cancer.,review of systems: , significant for ankle swelling.  the patient also wears glasses for vision and has dentures.  she does complain of shortness of breath with exertion.  she also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  the patient denies ulcerative colitis, crohn disease, bleeding diathesis, liver disease, or kidney disease.  she denies chest pain, cardiac disease, cancer, and stroke.,physical examination:  ,the patient is a well-nourished, well-developed female, in no distress.  eye exam:  pupils equal and reactive to light.  extraocular motions are intact.  neck exam:  no cervical lymphadenopathy.  midline trachea.  no carotid bruits.  nonpalpable thyroid.  neuro exam:  gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  lung exam:  clear breath sounds without rhonchi or wheezes.  cardiac exam:  regular rate and rhythm without murmur or bruits.  abdominal exam:  positive bowel sounds.  soft, nontender, obese, and nondistended abdomen.  lap cholecystectomy scars noted.  no obvious hernias.  no organomegaly appreciated.  lower extremity exam:  edema 1+.  dorsalis pedis pulses 2+.,assessment:  ,the patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  the patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,plan: , in preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  i recommended the patient undergo an upper gi series prior to surgery due to find her upper gi anatomy.  also the patient will meet with the dietitian and psychologist as per her usual routine.  i have recommended approximately six to eight weeks of medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.",4
"reason for consult: , peripheral effusion on the cat scan.,history of present illness: , the patient is a 70-year-old caucasian female with prior history of lung cancer, status post upper lobectomy.  she was recently diagnosed with recurrent pneumonia and does have a cancer on the cat scan, lung cancer with metastasis.  the patient had a visiting nurse for christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  she had a cat scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  she had an echo done, which shows moderate pericardial effusion with early tamponade.  the patient has underlying shortness of breath because of copd, emphysema and chronic cough.  however, denies any dizziness, syncope, presyncope, palpitation.  denies any prior history of coronary artery disease.,allergies: , no known drug allergies.,medications: , at this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, ambien.  she is on oxygen and nebulizer.,past medical history: , history of copd, emphysema, pneumonia, and lung cancer.,past surgical history:  ,hip surgery and resection of the lung cancer 10 years ago.,social history:,  still smokes, but less than before.  drinks socially.,family history:,  noncontributory.,review of systems: , denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,physical examination:,general:  the patient is comfortable not in any distress.,vital signs:  blood pressure 121/79, pulse rate 94, respiratory rate 19, and temperature 97.6.,heent:  atraumatic and normocephalic.,neck:  supple.  no jvd.  no carotid bruit.,chest:  breath sounds vesicular.  clear on auscultation.,heart:  pmi could not be localized.  s2 and s2 regular.  no s3, no s4.  no murmur.,abdomen:  soft and nontender.  positive bowel sounds.,extremities:  no cyanosis, clubbing, or edema.  pulse 2+.,cns:  alert, awake, and oriented x3.,ekg shows normal sinus rhythm, low voltage.,laboratory data: , white cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  sodium 135, potassium 5, bun 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,diagnostic studies:,  chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  ct abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,assessment:,1.  moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  lung cancer with metastasis most likely.,3.  pneumonia.,4.  copd.,plan: , we will get ct surgery consult for pericardial window.  continue present medication.",2
"reason for consultation: , glioma.,history of present illness:,  the patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  she underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  she did well for the next 10 years or so, and developed parkinson disease, possibly related to radiation therapy.  she has been followed by neurology, dr. z, to treat seizure activity.  she has a vagal stimulator in place to help control her seizure activity.,over the last few months, she has had increasing weakness on the right side.  she has been living in a nursing home.  she has not been able to walk, and she has not been able to write for the past three to four years.,mri scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  there was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,surgery was performed during this admission to remove some of the posterior part of the tumor.  she tolerated the procedure well.  she has noticed no worsening or improvement in her weakness.  pathology shows a low- to intermediate-grade glioma.  the second opinion by dr. a is still pending.,the patient is feeling well today.  she is not having headache, and reports no new neurologic symptoms.  she has not had leg swelling, cough, shortness of breath, or chest pain.,current medications:  ,1.  ambien p.r.n.  ,2.  vicodin p.r.n.  ,3.  actonel every sunday.  ,4.  colace.  ,5.  felbatol 1200 mg b.i.d.  ,6.  heparin injections for prophylaxis.  ,7.  maalox p.r.n.  ,8.  mirapex 0.5 mg t.i.d.  ,9.  protonix 40 mg daily.  ,10.  tylenol p.r.n.  ,11.  zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  she has zofran p.r.n., albuterol inhaler q.i.d., and aggrenox, which she is to start.,the rest of the history is mostly from the chart.,allergies: , she is allergic to penicillin.,past medical history:  ,1.  parkinson's, likely secondary to radiation therapy.,2.  history of prior stroke.,3.  seizure disorder secondary to her brain tumor.,4.  history of urinary incontinence.,5.  she has had hip fractures x2, which have required surgical pinning.,6.  appendectomy.,7.  cholecystectomy.,social history:,  shows that she does not smoke cigarettes or drink alcohol.  she lives in a nursing home.,family history:,  shows a family history of breast cancer.,physical examination:,  ,general:  today, she is sitting up in the chair, alert, and appropriate.  she tends to lean towards the right.  the right arm and hand are noticeably weaker than the left.  she is quite thin.,vital signs:  temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,heent:  there is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  the oropharynx shows no thrush or mucositis.,lungs:  clear bilaterally to auscultation.,cardiac:  exam shows regular rate.,abdomen:  soft.,extremities:  no peripheral edema or evidence of deep venous thrombosis (dvt) is noted on the lower extremities.,impression and plan:,  progressive low-grade glioma, now more than 20 years since initially diagnosed.  she is status post craniotomy for debulking and has done well with the surgery.,we reviewed the phase ii trials that have used temodar in the setting of grade 2 gliomas.  although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  we discussed using temodar after she heals from her surgery.  toxicities would include fatigue, nausea, and myelosuppression primarily.",15
"preoperative diagnoses:  ,1.  large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2.  cervical spondylosis.,3.  cervical stenosis, c5-c6 secondary to above (723.0).,postoperative diagnoses:  ,1.  large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2.  cervical spondylosis.,3.  cervical stenosis, c5-c6 secondary to above (723.0), with surgical findings confirmed.,procedures: , ,1.  anterior cervical discectomy at c5-c6 with spinal cord and spinal canal decompression (63075).,2.  anterior interbody fusion at c5-c6, (22554) utilizing bengal cage (22851).,3.  anterior instrumentation for stabilization by uniplate construction, c5-c6, (22845); with intraoperative x-ray times two.,anesthesia: , general.,service: , neurosurgery.,operation:  ,the patient was brought into the operating room, placed in a supine position where general anesthesia was administered.  then the anterior aspect of the neck was prepped and draped in a routine sterile fashion.  a linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case.  a prominent anterior osteophyte at c5-c6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved.  this allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to pathology for a permanent section.  residual osteophytes and disc fragments were removed with 1 and 2-mm micro kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well.  a hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status.  at no time during the case was evidence of csf leakage, and hemostasis was readily achieved with pledgets of gelfoam subsequently removed with copious amounts of antibiotic irrigation.  once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied.  further stability was added nonetheless with an appropriate size uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner.  the wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 vicryl, and the skin with a subcuticular stitch of 4-0 vicryl, and this was steri-stripped for reinforcement, and a sterile dressing was applied, incorporating a penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner.  once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,at the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.",25
"subjective:,  the patient presents with mom for a first visit to our office for a well-child check with concern of some spitting up quite a bit.  mom wants to make sure that this is normal.  the patient is nursing well every two to three hours.  she does have some spitting up on occasion.  it has happened two or three times with some curdled appearance x 1.  no projectile in nature, nonbilious.  normal voiding and stooling pattern.  growth and development:  denver ii normal, passing all developmental milestones per age.  see denver ii form in the chart.,past medical history:,  mom reports uncomplicated pregnancy with prenatal care provided by dr. xyz in wichita, kansas.  delivery after induction secondary to postdate at st. joseph hospital.  infant delivered by svd with birth weight of 6 pounds 13 ounce.  length of 19 inches.  did well after delivery and dismissed to home with mom.  received hepatitis b #1 prior to dismissal.  no other hospitalizations.  no surgeries.  no known medical allergies.  no medications.  mom has tried mylicon drops on occasion.,family history: , significant for cardiovascular disease, hypertension, diabetes mellitus and thyroid problems in maternal and paternal grandparents.  healthy mother, father.  there is also history of breast, colon and ovarian cancer on the maternal side of the family, her grandmother who is present at visit today.  there is history of asthma in the patient's father.,social history:,  the patient lives at home with 23-year-old mother, who is a homemaker and 24-year-old father, john, who is a supervisor at excel.  the family lives in bentley, kansas.  no smoking in the home.  family does have one pet cat.,review of systems:,  as per hpi, otherwise, negative.,objective:,  weight:  7 pounds 12 ounces.  height:  21 inches.  head circumference:  35 cm.  temperature:  97.2 degrees.,general:  well-developed, well-nourished, cooperative, alert, interactive 2-week-old white female in no acute distress.,heent:  atraumatic, normocephalic.  anterior fontanel is soft and flat.  pupils are equal, round and reactive.  sclerae clear.  red reflexes present bilaterally.  tms are clear bilaterally.  oropharynx:  mucous membranes are moist and pink.,neck:  supple, no lymphadenopathy.,chest:  clear to auscultation bilaterally.  no wheeze or crackles.  good air exchange.,cardiovascular:  regular rate and rhythm.  no murmur.  good pulses bilaterally.,abdomen:  soft, nontender, nondistended.  positive bowel sounds.  no mass nor organomegaly.,genitourinary:  tanner i female genitalia.  femoral pulses are equal bilaterally.  no rash.,extremities:  full range of motion.  no cyanosis, clubbing or edema.  negative ortolani or barlow maneuver.,back:  straight.  no scoliosis.,integument:  warm, dry and pink without lesions.,neurologic:  alert.  good muscle tone and strength.,assessment/plan:,1.  well 2-week-old white female.,2.  anticipatory guidelines for growth, diet, development, safety issues as well as immunizations and visitation schedule.  gave 2-week well-child check handout and american academy of pediatrics book birth to 5 years to mom and family.,3.  call the office or on-call physician if the patient has fever, feeding problems or breathing problems.  otherwise plan to recheck at 1-month of age.",4
"exam:,  ct head.,reason for exam:,  seizure disorder.,technique:,  noncontrast ct head.,findings: , there is no evidence of an acute intracranial hemorrhage or infarction.  there is no midline shift, intracranial mass, or mass effect.  there is no extra-axial fluid collection or hydrocephalus.  visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,impression:,  no acute process in the brain.",20
"preoperative diagnosis: , idiopathic toe walker.,postoperative diagnosis: , idiopathic toe walker.,procedure: , bilateral open achilles lengthening with placement of short leg walking cast.,anesthesia: , surgery performed under general anesthesia.  a total of 10 ml of 0.5% marcaine local anesthetic was used.,complications:  ,no intraoperative complications.,drains: , none.,specimens: , none.,tourniquet time:  ,on the left side was 30 minutes, on the right was 21 minutes.,history and physical:,  the patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year.  the patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally.  he does not walk with a crouched gait but does toe walk.  given his tightness, surgery versus observation was recommended to the family.  family however wanted to correct his toe walking.  surgery was then discussed.  risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems.  all questions were answered and parents agreed to above surgical plan.,procedure in detail: , the patient was taken to the operating room and placed supine on the operating table  general anesthesia was then administered.  the patient received ancef preoperatively.  the patient was then subsequently placed prone with all bony prominences padded.  two bilateral nonsterile tourniquets were placed on each thigh.  both extremities were then prepped and draped in a standard surgical fashion.  we turned our attention first towards the left side.  a planned incision of 1 cm medial to the achilles tendon was marked on the skin.  the extremity was wrapped in esmarch prior to inflation of tourniquet to 250 mmhg.  incision was then made and carried down through subcutaneous fat down to the tendon sheath.  achilles tendon was identified and z-lengthening was done with the medial distal half cut.  once z-lengthening was completed proximally, the length of the achilles tendon was then checked.  this was trimmed to obtain an end-on-end repair with 0 ethibond suture.  this was also oversewn.  wound was then irrigated.  achilles tendon sheath was reapproximated using 2-0 vicryl as well as the subcutaneous fat.  the skin was closed using 4-0 monocryl.  once the wound was cleaned and dried and dressed with steri-strips and xeroform, the area was injected with 0.5% marcaine.  it was then dressed with 4 x 4 and webril.  tourniquet was released at 30 minutes.  the same procedure was repeated on the right side with tourniquet time of 21 minutes.  while the patient was still prone, two short-leg walking casts were then placed.  the patient tolerated the procedure well and was subsequently flipped supine on to hospital gurney and taken to pacu in stable condition.,postoperative plan:  ,the patient will be discharged on the day of surgery.  he may weightbear as tolerated in his cast, which he will have for about 4 to 6 weeks.  he is to follow up in approximately 10 days for recheck as well as prescription for intended afos, which he will need up to 6 months.  the patient may or may not need physical therapy while his achilles lengthenings are healing.  the patient is not to participate in any pe for at least 6 months.  the patient is given tylenol no. 3 for pain.",36
"preoperative diagnoses: , history of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,postoperative diagnoses: , history of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,operations:,1.  wound debridement x2, including skin, subcutaneous, and muscle.,2.  insertion of tissue expander to the medial wound.,3.  insertion of tissue expander to the lateral wound.,complications: , none.,tourniquet: , none.,anesthesia:  ,general.,indications: , this patient developed a compartment syndrome.  she underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg.  she was doing very well and was obviously improving.,the swelling was reduced.  a compartment pressure had obviously improved based on examination.  she was therefore indicated for placement of tissue expander for ventral wound closure.  the risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well.  risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  she understood them well.  all questions were answered, and she signed the consent for the procedure as described.,description of the procedure:,  the patient was placed on the operating table and general anesthesia was achieved.  the medial wound was noted to be approximately 10.5 cm in length x 4 cm.  the lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width.  both wounds were then thoroughly debrided.  the debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion.  this involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides.  at this point adequate debridement was performed and healthy tissue did appear to be present.  initially on the medial wound i did place the dermaclose rc continuous external tissue expander.  on the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately.  i then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor.  i then did place adequate tension on the sutures.  continued tension will be noted after engaging the tension controller.  at this point i performed the similar procedure to the lateral wound.  the skin anchors were placed separately and appropriately on either side of the skin margin.  the line loop from the tension controller was placed in lace like manner through the skin anchors.  the tension controller was then attached to the mid anchor and appropriate tension was applied.,it must be noted i did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained.  adequate tension was placed in this region.  a non thick dressing was then applied to the open-wound region and sterile dressing was then applied.  no complications were encountered throughout the procedure and the patient tolerated the procedure well.  the patient was taken to recovery room in stable condition.",36
"exam:,mri left knee,clinical:,this is a 41 -year-old-male with knee pain, mobility loss and swelling. the patient had a twisting injury one week ago on 8/5/05. the examination was performed on 8/10/05,findings:,there is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,there is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,there is an interstitial sprain/partial tear of the anterior cruciate ligament. there is no complete tear or discontinuity, and the ligament has a celery stick appearance.,normal posterior cruciate ligament.,normal medial collateral ligament.,there is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. the fibular attachment is intact.,normal biceps femoris tendon, popliteus tendon and iliotibial band.,normal quadriceps and patellar tendons.,there are no fractures.,there is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. there are milder changes within the medial femorotibial compartments. there are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,there is a joint effusion. there is synovial thickening.,impression:,probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,interstitial sprain/partial tear of the anterior cruciate ligament.,arthrosis, joint effusion and synovial hypertrophy.,there are several areas of focal prominent medullary fat within the medial and lateral femoral condyles.",31
"procedure:, placement of scott cannula, right lateral ventricle.,description of the operation:, the right side of the head was shaved and the area was then prepped using betadine prep. following an injection with xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. a twist drill was made with the hand drill through the dura. a scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear csf. the scott cannula was secured to the skin using 3-0 silk sutures. this will be connected to external drainage set at 10 cm of water.",36
"preoperative/postoperative diagnoses:,1.  severe tracheobronchitis.,2.  mild venous engorgement with question varicosities associated pulmonary hypertension.,3.  right upper lobe submucosal hemorrhage without frank mass underneath it status post biopsy.,procedure performed: , flexible fiberoptic bronchoscopy with:,a.  right lower lobe bronchoalveolar lavage.,b.  right upper lobe endobronchial biopsy.,samples: , bronchoalveolar lavage for cytology and for microbiology of the right lower lobe endobronchial biopsy of the right upper lobe.,indications: , the patient with persistent hemoptysis of unclear etiology.,procedure: , after obtaining informed consent, the patient was brought to bronchoscopy suite.  the patient had previously been on coumadin and then heparin.  heparin was discontinued approximately one-and-a-half hours prior to the procedure.  the patient underwent topical anesthesia with 10 cc of 4% xylocaine spray to the left nares and nasopharynx.  blood pressure, ekg, and oximetry monitoring were applied and monitored continuously throughout the procedure.  oxygen at two liters via nasal cannula was delivered with saturations in the 90% to 100% throughout the procedure.  the patient was premedicated with 50 mg of demerol and 2 mg of versed.  after conscious sedation was achieved, the bronchoscope was advanced through the left nares into the nasopharynx and oropharynx.  there was minimal redundant oral soft tissue in the oropharynx.  there was mild erythema.  clear secretions were suctioned.,additional topical anesthesia was applied to the larynx and then throughout the tracheobronchial tree for the procedure, a total of 16 cc of 2% xylocaine was applied.  vocal cord motion was normal.  the bronchoscope was then advanced through the larynx into the trachea.  there was evidence of moderate inflammation with prominent vascular markings and edema.  no frank blood was visualized.  the area was suction clear of copious amounts of clear white secretions.  additional topical anesthesia was applied and the bronchoscope was advanced into the left main stem.  the bronchoscope was then sequentially advanced into each segment and sub-segment of the left upper lobe and left lower lobe.  there was significant amount of inflammation, induration, and vascular tortuosity in these regions.  no frank blood was identified.  no masses or lesions were identified.  there was senile bronchiectasis with slight narrowing and collapse during the exhalation.  the air was suctioned clear.  the bronchoscope was withdrawn and advanced into the right main stem.  bronchoscope was introduced into the right upper lobe and each sub-segment was visualized.  again significant amounts of tracheobronchitis was noted with vascular infiltration.  in the sub-carina of the anterior segment of the right upper lobe, there was evidence of a submucosal hematoma without frank mass underneath this.  the bronchoscope was removed and advanced into the right middle and right lower lobe.  there was marked injection and inflammation in these regions.  in addition, there was marked vascular engorgement with near frank varicosities identified throughout the region.  again, white clear secretions were identified.  no masses or other processes were noted.  the area was suctioned clear.  a bronchoalveolar lavage was subsequently performed in the anterior segment of the right lower lobe.  the bronchoscope was then withdrawn and readvanced into the right upper lobe.  endobronchial biopsies of the carina of the sub-segment and anterior segment of the right upper lobe were obtained.  minimal hemorrhage occurred after the biopsy, which stopped after 1 cc of 1:1000 epinephrine.  the area remained clear.  no further hemorrhage was identified.  the bronchoscope was subsequently withdrawn.  the patient tolerated the procedure well and was stable throughout the procedure.  no further hemoptysis was identified.  the patient was sent to recovery in good condition.",2
"history of present illness: , this is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  the patient also has a positive history of smoking in the past.  at the present time, he is admitted for continued,management of respiratory depression with other medical complications.  the patient was treated for multiple problems at jefferson hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  in addition, he also developed cardiac complications including atrial fibrillation.  the patient was evaluated by the cardiologist as well as the pulmonary service and urology.  he had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  he subsequently underwent cardiac arrest and he was resuscitated at that time.  he was intubated and placed on mechanical ventilatory support.  subsequent weaning was unsuccessful.  he then had a tracheostomy placed.,current medications:,1.  albuterol.,2.  pacerone.,3.  theophylline,4.  lovenox.,5.  atrovent.,6.  insulin.,7.  lantus.,8.  zestril.,9.  magnesium oxide.,10.  lopressor.,11.  zegerid.,12.  tylenol as needed.,allergies:,  penicillin.,past medical history:,1.  history of coal miner's disease.,2.  history of copd.,3.  history of atrial fibrillation.,4.  history of coronary artery disease.,5.  history of coronary artery stent placement.,6.  history of gastric obstruction.,7.  history of prostate cancer.,8.  history of chronic diarrhea.,9.  history of pernicious anemia.,10.  history of radiation proctitis.,11.  history of anxiety.,12.  history of ureteral stone.,13.  history of hydronephrosis.,social history: , the patient had been previously a smoker.  no other could be obtained because of tracheostomy presently.,family history: , noncontributory to the present condition and review of his previous charts.,systems review: , the patient currently is agitated.  rapidly moving his upper extremities.  no other history regarding his systems could be elicited from the patient.,physical exam:,general:  the patient is currently agitated with some level of distress.  he has rapid respiratory rate.  he is responsive to verbal commands by looking at the eyes.,vital signs:  as per the monitors are stable.,extremities:  inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage ii especially over the dorsum of the hands and forearm areas.  there is also edema of the forearm extending up to the mid upper arm area.  palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  there is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,impression:,1.  ulceration of bilateral upper extremities.,2.  cellulitis of upper extremities.,3.  lymphedema of upper extremities.,4.  other noninfectious disorders of lymphatic channels.,5.  ventilatory-dependent respiratory failure.",4
"preoperative diagnosis:,  pelvic pain.,postoperative diagnoses:,1.  pelvic pain.,2.  pelvic endometriosis.,3.  pelvic adhesions.,procedure performed:,1.  laparoscopy.,2.  harmonic scalpel ablation of endometriosis.,3.  lysis of adhesions.,4.  cervical dilation.,anesthesia:  ,general.,specimen:  ,peritoneal biopsy.,estimated blood loss:,  scant.,complications: , none.,findings: , on bimanual exam, the patient has a small, anteverted, and freely mobile uterus with no adnexal masses.  laparoscopically, the patient has large omental to anterior abdominal wall adhesions along the left side of the abdomen extending down to the left adnexa.  there are adhesions involving the right ovary to the anterior abdominal wall and the bowel.  there are also adhesions from the omentum to the anterior abdominal wall near the liver.  the uterus and ovaries appear within normal limits other than the adhesions.  the left fallopian tube grossly appeared within normal limits.  the right fallopian tube was not well visualized but appeared grossly scarred and no tubal end was visualized.  there was a large area of endometriosis, approximately 1 cm wide in the left ovarian fossa and there was a small spot of endometriosis in the posterior cul-de-sac.  there was also vesicular appearing endometriosis lesion in the posterior cul-de-sac.,procedure:  ,the patient was taken in the operating room and generalized anesthetic was administered.  she was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  after exam under anesthetic, weighted speculum was placed in the vagina.  the anterior lip of the cervix was grasped with vulsellum tenaculum.  the uterus was sounded and then was serially dilated with hank dilators to a size 10 hank, then the uterine manipulator was inserted and attached to the anterior lip of the cervix.  at this point, the vulsellum tenaculum was removed along with the weighted speculum and attention was turned towards the abdomen.  an approximately 2 cm incision was made immediately inferior to the umbilicus with the skin knife.  the superior aspect of the umbilicus was grasped with a towel clamp.  the abdomen was tented up and a veress needle inserted through this incision.  when the veress needle was felt to be in place, deep position was checked by placing saline in the needle.  this was seen to freely drop in the abdomen so it was connected to co2 gas.  again, this was started at the lowest setting, was seen to flow freely, so it was advanced to the high setting.  the abdomen was then insufflated to an adequate distention.  once an adequate distention was reached, the co2 gas was disconnected.  the veress needle was removed and a size #11 step trocar was placed.  next, the laparoscope was inserted through this port.  the medial port was connected to co2 gas.  next, a 1 cm incision was made in the midline approximately 2 fingerbreadths above the pubic symphysis.  through this, a veress needle was inserted followed by size #5 step trocar and this procedure was repeated under direct visualization on the right upper quadrant lateral to the umbilicus and a size #5 trocar was also placed.  next, a grasper was placed through the suprapubic port.  this was used to grasp the bowel that was adhesed to the right ovary and the harmonic scalpel was then used to lyse these adhesions.  bowel was carefully examined afterwards and no injuries or bleeding were seen.  next, the adhesions touching the right ovary and anterior abdominal wall were lysed with the harmonic scalpel and this was done without difficulty.  there was a small amount of bleeding from the anterior abdominal wall peritoneum.  this was ablated with the harmonic scalpel.  the harmonic scalpel was used to lyse and ablate the endometriosis in the left ovarian fossa and the posterior cul-de-sac.  both of these areas were seen to be hemostatic.  next, a grasper was placed and was used to bluntly remove the vesicular lesion from the posterior cul-de-sac.  this was sent to pathology.  next, the pelvis was copiously irrigated with the nezhat dorsi suction irrigator and the irrigator was removed.  it was seen to be completely hemostatic.  next, the two size #5 ports were removed under direct visualization.  the camera was removed.  the abdomen was desufflated.  the size #11 introducer was replaced and the #11 port was removed.,next, all the ports were closed with #4-0 undyed vicryl in a subcuticular interrupted fashion.  the incisions were dressed with steri-strips and bandaged appropriately and the patient was taken to recovery in stable condition and she will be discharged home today with darvocet for pain and she will follow-up in one week in the clinic for pathology results and to have a postoperative check.",22
"reason for visit:  ,followup cervical spinal stenosis.,history of present illness:  ,ms. abc returns today for followup regarding her cervical spinal stenosis.  i have last seen her on 06/19/07.  her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,i referred her to obtain a cervical spine mri.,she returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  she had some physical therapy, which has been helping with the neck pain.  the right hand weakness continues.  she states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  she states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,she has been undergoing nonoperative management by dr. x and feels this has been helping her neck pain, but not the upper extremity symptoms.,she denies any bowel and bladder dysfunction.  no lower back pain, no lower extremity pain, and no instability with ambulation.,review of systems:,  negative for fevers, chills, chest pain, and shortness of breath.,findings:  ,on examination, ms. abc is a very pleasant well-developed, well-nourished female in no apparent distress.  alert and oriented x3.  normocephalic and atraumatic.  afebrile to touch.,she ambulates with a normal gait.,motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,light touch sensation decreased in the right greater than left c6 distribution.  biceps and brachioradialis reflexes are 3 plus.  hoffman sign normal bilaterally.,lower extremity strength is 5 out of 5 in all muscle groups.  patellar reflex is 3 plus.  no clonus.,cervical spine radiographs dated 06/21/07 are reviewed.,they demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at c4-5, c5-6, c6-7, and c3-4 demonstrates only minimal if any degenerative disk disease.  there is no significant instability seen on flexion-extension views.,updated cervical spine mri dated 06/21/07 is reviewed.,it demonstrates evidence of moderate stenosis at c4-5, c5-6.  these stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the c6-7 level.  minimal degenerative disk disease is seen at the c6-7.  this stenosis is greater than c5-6 and the next level is more significantly involved at c4-5.,effacement of the ventral and dorsal csf space is seen at c4-5, c5-6.,assessment and plan: , ms. abc's history, physical examination, and radiographic findings are compatible with c4-5, c5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,i spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,i laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,the patient states she would like to avoid injections and is somewhat afraid of having these done.  i explained to her that they may help to improve her symptoms, although they may not help with the weakness.,she feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,i described the procedure consisting of c4-5, c5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,i explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  she understands.,i discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,i also discussed the option of disk arthroplasty.  she understands.,she would like to proceed with the surgery, relatively soon.  she has her birthday coming up on 07/20/07 and would like to hold off, until after then.  our tentative date for the surgery is 08/01/07.  she will go ahead and continue the preoperative testing process.",20
"ct angiography chest with contrast,reason for exam: , chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,technique:  ,axial ct images of the chest were obtained for pulmonary embolism protocol utilizing 100 ml of isovue-300.,findings:  ,there is no evidence for pulmonary arterial embolism.,the lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax.  no abnormal mediastinal or hilar lymphadenopathy is seen.,limited images of the upper abdomen are unremarkable.  no destructive osseous lesion is detected.,impression: , negative for pulmonary arterial embolism.",2
"chief complaint:,  the patient comes for three-week postpartum checkup, complaining of allergies.,history of present illness:,  she is doing well postpartum.  she has had no headache.  she is breastfeeding and feels like her milk is adequate.  she has not had much bleeding.  she is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  she has not yet had sexual intercourse.  she does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  she has not been particularly constipated but her husband says she is not eating her vegetables like she should.  her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,medications:,  prenatal vitamins.,allergies:,  she thinks to benadryl.,family history: , mother is 50 and healthy.  dad is 40 and healthy.  half-sister, age 34, is healthy.  she has a sister who is age 10 who has some yeast infections.,physical examination:,vitals:  weight:  124 pounds.  blood pressure 96/54.  pulse:  72.  respirations:  16.  lmp:  10/18/03.  age:  39.,heent:  head is normocephalic.  eyes:  eoms intact.  perrla.  conjunctiva clear.  fundi:  discs flat, cups normal.  no av nicking, hemorrhage or exudate.  ears:  tms intact.  mouth:  no lesion.  throat:  no inflammation.  she has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,abdomen:  soft.  no masses.,pelvic:  uterus is involuting.,rectal:  she has one external hemorrhoid which has inflamed.  stool is guaiac negative and using anoscope, no other lesions are identified.,assessment/plan:,  satisfactory three-week postpartum course, seasonal allergies.  we will try patanol eyedrops and allegra 60 mg twice a day.  she was cautioned about the possibility that this may alter her milk supply.  she is to drink extra fluids and call if she has problems with that.  we will try proctofoam hc.  for the hemorrhoids, also increase the fiber in her diet.  that prescription was written, as well as one for allegra and patanol.  she additionally will be begin on micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  she will call and return if she continues to have problems with allergies.  meantime, rechecking in three weeks for her final six-week postpartum checkup.",33
"admission diagnoses:,1.  menometrorrhagia.,2.  dysmenorrhea.,3.  small uterine fibroids.,discharge diagnoses:,1.  menorrhagia.,2.  dysmenorrhea.,3.  small uterine fibroids.,operation performed:  ,total vaginal hysterectomy.,brief history and physical:  ,the patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  she is having increasing menometrorrhagia and dysmenorrhea.  ultrasound shows a small uterine fibroid.  she has failed oral contraceptives and surgical therapy is planned.,past history: , significant for reflux.,surgical history:  ,tubal ligation.,physical examination: , a top normal sized uterus with normal adnexa.,laboratory values:  ,her discharge hemoglobin is 12.4.,hospital course: , she was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  postoperatively, she has done well.  bowel and bladder function have returned normally.  she is ambulating well, tolerating a regular diet.  routine postoperative instructions given and said follow up will be in four weeks in the office.,discharge medications: , preoperative meds plus vicodin for pain.,discharge condition: , good.",9
"preoperative diagnosis: , acute appendicitis.,postoperative diagnosis: , perforated meckel's diverticulum.,procedures performed:,1.  diagnostic laparotomy.,2.  exploratory laparotomy.,3.  meckel's diverticulectomy.,4.  open incidental appendectomy.,5.  peritoneal toilet.,anesthesia: , general endotracheal.,estimated blood loss:  ,300 ml.,urine output: , 200 ml.,total fluid:,  1600 ml.,drain:,  jp x1 right lower quadrant and anterior to the rectum.,tubes:,  include an ng and a foley catheter.,specimens: , include meckel's diverticulum and appendix.,complications: , ventilator-dependent respiratory failure with hypoxemia following closure.,brief history: , this is a 45-year-old caucasian gentleman presented to abcd general hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,the pain was very vague and progressed in intensity.  the patient has had anorexia with decrease in appetite.  his physical examination revealed the patient to be febrile with the temperature of 102.4.  he had right lower quadrant and suprapubic tenderness with palpation with rovsing sign and rebound consistent with acute surgical abdomen.  the patient was presumed acute appendicitis and was placed on iv antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  he was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,operative findings: , diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  there was large amounts of purulent drainage.  the appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  it was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  upon exploration of the ileum, there was noted to be a ruptured meckel's diverticulum, this was resected.  additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  the patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  the patient was closed and did develop some hypoxemia after closure.  he remained ventilated and was placed on a large amount of ________.  his hypoxia did resolve and he remained intubated and proceed to the critical care complex or postop surgical care.,operative procedure:,  the patient was brought to the operative suite and placed in the supine position.  he did receive preoperative iv antibiotics, sequential compression devices, ng tube placement with foley catheter, and heparin subcutaneously.  the patient was intubated by the anesthesia department.  after adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with betadine solution.  utilizing a #10 blade scalpel, an infraumbilical incision was created.  the veress needle was inserted into the abdomen.  the abdomen was insufflated to approximately 15 mmhg.  a #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  a right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  the instruments were then removed.  the abdomen was then deflated.  utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,the incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  the posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  incision was carried down to the midline within the linea alba.  once the abdomen was opened, there was noted to be gross purulent drainage.  the ileum was explored and there was noted to be a perforated meckel's diverticulum.  decision to resect the diverticulum was performed.,the blood supply to the meckel's diverticulum was carefully dissected free and a #3-0 vicryl was used to tie off the blood supply to the meckel's diverticulum.  clamps were placed to the proximal supply to the meckel's diverticulum was tied off with #3-0 vicryl sutures.  the meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a gia stapling device, the diverticulum was transected.  there was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  next, decision was decided to go ahead and perform an appendectomy.  mesoappendix was doubly clamped with hemostats and cut with metzenbaum scissors.  the appendiceal artery was identified and was clamped between two hemostats and transected as well.  once the appendix was completely freed of the surrounding inflammation and adhesion.  a plain gut was placed at the base of the appendix and tied down.  the appendix was milked distally with a straight stat and clamped approximately halfway.  a second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  the appendiceal stump was then inverted with a pursestring suture of #2-0 vicryl suture.  once the ________ was completed, decision to place a jp drain within the right lower quadrant was performed.  the drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  it was sewn in place with a #3-0 nylon suture.  the abdomen was then irrigated with copious amounts of warmed normal saline.  the remainder of the abdomen was unremarkable for pathology.  the omentum was replaced over the bowel contents and utilizing #1-0 pds suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  the previous laparoscopic sites were also closed with staples.  sterile dressings were placed over the wound with adaptic and 4x4s and covered with abds.  jps replaced with bulb suction.  ng tube and foley catheter were left in place.  the patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,the patient will proceed to the critical care complex where he will be closely evaluated and followed in his postoperative course.  to remain on iv antibiotics and we will manage ventilatory-dependency of the patient.",36
"reason for referral:,  the patient was referred to me by dr. x of the clinic due to concerns regarding behavioral acting out as well as encopresis.  this is a 90-minute initial intake completed on 10/03/2007.  i met with the patient's mother individually for the entire session.  i reviewed with her the treatment, consent form, as well as the boundaries of confidentiality, and she stated that she understood these concepts.,presenting problems: , mother reported that her primary concern in regard to the patient had to do with his oppositionality.  she was more ambivalent regarding addressing the encopresis.  in regards to his oppositionality, she reported that the onset of his oppositionality was approximately at 4 years of age, that before that he had been a very compliant and happy child, and that he has slowly worsened over time.  she noted that the oppositionality occurred approximately after his brother, who has multiple medical problems, was born.  at that time, mother had spent 2 months back east with the brother due to his feeding issues and will have to go again next year.  she reported that in terms of the behaviors that he loses his temper frequently, he argues with her that he defies her authority that she has to ask him many times to do things, that she has to repeat instructions, that he ignores her, that he whines, and this is when he is told to do something that he does not want to do.  she reported that he deliberately annoys other people, that he can be angry and resentful.  she reported that he does not display these behaviors with the father nor does he display them at home, but they are specific to her.  she reported that her response to him typically is that she repeats what she wants him to do many, many times, that eventually she gets upset.  she yells at him, talks with him, and tries to make him go and do what she wants him to do.  mother also noted that she probably ignores some his misbehaviors.  she stated that the father tends to be more firm and more direct with him, and that, the father sometimes thinks that the mother is too easy on him.  in regards to symptoms of depression, she denied symptoms of depression, noting that he tends to only become unhappy when he has to do something that he does not want to do, such as go to school or follow through on a command.  she denied any suicidal ideation.  she denied all symptoms of anxiety.  ptsd was denied.  adhd symptoms were denied, as were all other symptoms of psychopathology.,in regards to the encopresis, she reported that he has always soiled, he does so 2 to 3 times a day.  she reported that he is concerned about this issue.  he currently wears underwear and had a pull-up.  she reported that he was seen at the gastroenterology department here several years ago, and has more recently been seen at the diseases center, seen by dr. y, reported that the last visit was several months ago, that he is on miralax.  he does sit on the toilet may be 2 times a day, although that is not consistent.  mother believes that he is probably constipated or impacted again.  he refuses to eat any fiber.  in regards to what happens when he soils, mother basically takes full responsibility.  she cleans and changes his underwear, thinks of things that she has tried, she mostly gets frustrated, makes negative comments, even though she knows that he really cannot help it.  she has never provided him with any sort of rewards, because she feels that this is something he just needs to learn to do.  in regards to other issues, she noted that he becomes frustrated quite easily, especially around homework, that when mother has to correct him, or when he has had difficulty doing something that he becomes upset, that he will cry, and he will get angry.  mother's response to him is that either she gets agitated and raises her voice, tells him to stop etc.  mother reported it is not only with homework, but also with other tasks, such as if he is trying to build with his legos and things do not go well.,developmental background: , the patient was reported to be the 8 pound 12 ounce product of a planned and noncomplicated pregnancy and emergency cesarean delivery.  the patient presented in a breech position.  mother denied the use of drugs, alcohol, or tobacco during the pregnancy.  no sleeping or eating issues were present in the perinatal period.  temperament was described as easy.  he was described as a cuddly baby.  no concerns expressed regarding his developmental milestones.  no serious injuries reported.  no hospitalizations or surgeries.  no allergies.  the patient has been encopretic for all of his life.  he currently is taking miralax.,family background: , the patient lives with his mother who is age 37, and is primarily a homemaker, but does work approximately 48 hours a month as a beautician; with his father, age 35, who is a police officer; and also, with his younger brother who is age 3, and has significant medical problems as will be noted in a moment.  mother and father have been together since 1997, married in 1999.  the maternal grandmother and grandfather are living and are together, and live in the central california coast area.  there is one maternal aunt, age 33, and then, two adopted maternal aunt and uncle, age 18 and age 13.  in regards to the father's side of the family, the paternal grandparents are divorced.  grandfather was in arkansas, grandmother lives in dos palos.  the patient does not see his grandfather.  mother stated that her relationship with her child was as described, that he very much stresses her out, that she wishes that he was not so defiant, that she finds him to be a very stressful child to deal with.  in regards to the relationship with the father, it was reported that the father tends to leave most of the parenting over to the mother, unless she specifically asks him to do something, and then, he will follow through and do it.  he will step in and back mother up in terms of parenting, tell the child not to speak to his mother that way etc.  mother reported that he does spend some time with the children, but not as much as mother would like him to, but occasionally, he will go outside and do things with them.  the mother reported that sometimes she has a problem in interfering with his parenting, that she steps in and defends the patient.  it was reported that mother stated that she tries the parenting technique, primarily of yelling and tried time-out, although her description suggests that she is not doing time-out correctly, as he simply gets up from his time-out, and she does not follow through.  mother reported that she and the patient are very much alike in temperament, and this has made things more difficult.  mother tends to be stubborn and gets angry easily also.  mother reported becoming fatigued in her parenting, that she lets him get away with things sometimes because she does not want to punish him all day long, sometimes ignores problems that she probably should not ignore.  there was reported to be jealousy between the patient and his brother, b.  b evidently has some heart problems and feeding issues, and because of that, tends to get more attention in terms of his medical needs, and that the patient is very jealous of that attention and feels that b is favored and that he get things that the patient does not get, and that there is some tension between the brothers.  they do play well together; however, the patient does tend to be somewhat intrusive, gets in his space, and then, b will hit him.  mother reported that she graduated from high school, went to community college, and was an average student.  no learning problems.  mother has a history of depression.  she has currently been taking 100 mg of zoloft administered by her primary medical doctor.  she is not receiving counseling.  she has been on the medications for the last 5 years.  her dosage has not been changed in a year.  she feels that she is getting more irritable and more angry.  i  encouraged her to see a primary medical doctor.  mother has no drug or alcohol history.  father graduated from high school, went to the police academy, average student.  no learning problems, no psychological problems, no drug or alcohol problems are reported.  in terms of extended family, maternal grandmother as well as maternal great grandfather have a history of depression.  other psychiatric symptoms were denied in the family.,mother reported that the marriage is generally okay, that there is some arguing.  she reported that it was in the normal range.,academic background: , the patient attends the roosevelt elementary school, where he is in a regular first grade classroom with mrs. the patient.  this is in the kingsburg unified school district.  no behavior problems, academic problems were reported.  he does not receive special education services.,social history: , the patient was described as being able to make and keep friends, but at this point in time, there has been no teasing regarding smell from the encopresis.  he does have kids over to play at the house.,previous counseling:,  denied.,diagnostic summary and impression: , my impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued.  she also has not used any sort of rewards as a way to encourage him, in the encopresis.  the patient clearly qualifies for a diagnosis of disruptive behavior disorder, not otherwise specified, and possibly oppositional defiant disorder.  it would appear that mother needs help in her parenting, and that she tends to mostly use yelling and anger as a way, and tends to repeat herself a lot, and does not have a strategy for how to follow through and to deal with defiant behavior.  also, mother and father, may not be on the same page in terms of parenting.,plan:,  in terms of my plan, i will meet with the child in the next couple of weeks.  i also asked the mother to bring the father in, so he could be involved in the treatment also, and i gave the mother a behavioral checklist to be completed by herself and the father as well as the teacher.,dsm iv diagnoses:  ,axis i:  adjustment disorder with disturbance of conduct (309.3).  encopresis, without constipation, overflow incontinence (307.7),axis ii:  no diagnoses (v71.09).,axis iii:  no diagnoses.,axis iv:  problems with primary support group.,axis v:  global assessment of functioning equals 65.",30
"delivery note:  ,this is a 30-year-old g6, p5-0-0-5 with unknown lmp and no prenatal care, who came in complaining of contractions and active labor.  the patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  the patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  no meconium was noted.  infant was delivered on 12/25/08 at 2154 hours.  two doses of ampicillin was given prior to rupture of membranes.  gbs status unknown.  intrapartum events, no prenatal care.  the patient had epidural for anesthesia.  no observed abnormalities were noted on initial newborn exam.  apgar scores were 9 and 9 at one and five minutes respectively.  there was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  placenta was delivered spontaneously and was normal and intact.  there was a three-vessel cord.  baby was bulb suctioned and then sent to newborn nursery.  mother and baby were in stable condition.  ebl was approximately 500 ml, nsvd with postpartum hemorrhage.  no active bleeding was noted upon deliverance of the placenta.  dr. x attended the delivery with second year resident, dr. x. upon deliverance of the placenta, the uterus was massaged and there was good tone.  pitocin was started following deliverance of the placenta.  baby delivered vertex from oa position.  mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.",36
"cc: ,headache.,hx:, this 51 y/o rhm was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. he then stepped back and struck his back on a trailer hitch. there was no associated loc but he felt ""dazed."" he complained a ha since the accident. the following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. he has been lying in bed most of the time since the accident. he also complained of transient left lower extremity weakness. the night before admission he went to his bedroom and his girlfriend heard a loud noise. she found him on the floor unable to speak or move his left side well. he was taken to a local er. in the er experienced a spell in which he stared to the right for approximately one minute. during this time he was unable to speak and did not seem to comprehend verbal questions. this resolved. er staff noted decreased left sided movement and a left babinski sign.,he was given valium 5 mg, and dph 1.0g. a hct was performed and he was transferred to uihc.,pmh:, dm, coronary artery disease, left femoral neuropathy of unknown etiology. multiple head trauma in past (?falls/fights).,meds:, unknown oral med for dm.,shx:, 10+pack-year h/o tobacco use; quit 2 years ago. 6-pack beer/week. no h/o illicit drug use.,fhx:, unknown.,exam: ,70bpm, bp144/83, 16rpm, 36.0c,ms: alert and oriented to person, place, time. fluent speech.,cn: left lower facial weakness with right gaze preference. pupils 3/3 decreasing to 2/2 on exposure to light. optic disks flat.,motor: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. normal muscle tone and bulk.,sensory: withdrew equally to noxious stimulation in all four extremities. gait/station/coordination: not tested.,the general physical exam was unremarkable.,during the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. the entire spell lasted one minute.,during the episode he was verbally unresponsive. he appeared groggy and lethargic after the event.,hct without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,labs:, cbc, gs, pt/ptt were all wnl.,course:, the patient was diagnosed with a right frontal sah/contusion and post traumatic seizures. dph was continued and he was given a librium taper for possible alcoholic withdrawal. a neurosurgical consult was obtained. he did not receive surgical intervention and was discharged 12/1/92. neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. anterograde verbal and visual memory was severely impaired. speech became mildly dysarthric when fatigued. defective word finding. difficulty copying 2 of 3 three dimensional figures. recent head injury as well as a history of etoh abuse and multiple prior head injuries probably contribute to his deficits.",20
"chief complaint:, right-sided weakness.,history of present illness:, the patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. she was subsequently sent to abc medical center for evaluation and treatment. at abc, the patient was seen by dr. h including labs and a head ct which is currently pending. the patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. she does seem to comprehend words. the daughter states the patient is in the life care center, and she believes this started this morning. the patient denies headache, visual changes, chest pain and shortness of breath. these changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.,allergies:, no known drug allergies.,medications:, medications are taken from the paperwork from life care center and include: lortab 3-4 times a day for pain, ativan 0.25 mg by mouth every 12 hours p.r.n. pain, depakote er 250 mg p.o. q nightly, actos 15 mg p.o. t.i.d., lantus 35 units subcu q nightly, glipizide 10 mg p.o. q day, lanoxin 0.125 mg p.o. q day, lasix 40 mg p.o. q day, lopressor 50 mg p.o. b.i.d., insulin sliding scale, lunesta 1 mg p.o. q nightly, sorbitol 15 mg p.o. q day, zoloft 50 mg p.o. q nightly, dulcolax as needed for constipation.,past medical history:, significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).,social history:, the patient lives at life care center. she does not smoke, drink or use intravenous drugs.,family history:, negative for cerebrovascular accident or cardiac disease.,review of systems:, as in hpi. patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. she has had some difficulty expressing herself, but seems to comprehend speech as above. the patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.,physical examination:,vital signs: the patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. she is 95% on room air.,general: this is a pleasant elderly female who appears stated age, in mild distress.,heent: oropharynx is dry.,neck: supple with no jugular venous distention or thyromegaly.,respiratory: clear to auscultation. no wheezes, rubs or crackles.,cardiovascular: a 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.,abdomen: soft. normal bowel sounds.,extremities: no clubbing, cyanosis or edema. she does have bilateral above knee amputations.,neurologic: strength 2/5 in her right hand, 4/5 in her left hand. she does have mild right facial droop and an expressive aphasia.,vascular: the patient has good capillary refill in her fingertips.,laboratory data:, bun 52, creatinine 1.3. normal coags. glucose 220. white blood cell count 10,800. urinalysis has 608 white cells, 625 rbcs. head ct is currently pending. ekg shows normal sinus rhythm with mild st-depression and biphasic t-waves diffusely.,assessment and plan:,1. right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. at this point we will hydrate, treat her urinary tract infection, check an mri, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. start antiplatelet therapy and ask neuro to see the patient.,2. urinary tract infection. will treat with ceftriaxone, check urine culture data and adjust as needed.,3. dehydration. will hydrate with iv fluids and follow p.o. intake while holding diuretics.,4. diabetes mellitus type 2 uncontrolled. her sugar is 249. we will continue lantus insulin and sliding scale coverage, and check hemoglobin a1c to gauge prior control.,5. prophylaxis. will institute low molecular weight heparin and follow activity levels.",4
"postoperative diagnosis:  adenotonsillitis with hypertrophy.,operation performed:  adenotonsillectomy.,anesthesia:  general endotracheal.,indications:  the patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  adenotonsillectomy is indicated.,description of procedure:  the patient was placed on the operating room table in the supine position.  after adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  a mcivor mouth gag was applied.  the tongue was retracted anteriorly and the mcivor was gently suspended from a mayo stand.  a red rubber robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  the adenoids were removed with suction electrocautery under mere visualization.  the left tonsil was grasped with a curved allis forceps, retracted medially and the anterior tonsillar pillar was incised with bovie electrocautery.  the tonsil was removed from the superior and inferior pole using bovie electrocautery in its entirety in the subcapsular fashion.  the right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with bovie electrocautery.  the tonsil was removed from the superior pole and inferior pole using bovie electrocautery in its entirety in the subcapsular fashion.  the inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  copious saline irrigation of the oral cavity was then performed.  there was no further identifiable bleeding at the termination of the procedure.  the estimated blood loss was less than 10 ml.  the patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  there were no intraoperative complications.",36
"bilateral scrotal orchectomy,procedure:,:  the patient is placed in the supine position, prepped and draped in the usual manner.  under satisfactory general anesthesia, the scrotum was approached and through a transverse mid scrotal incision, the right testicle was delivered through the incision.  hemostasis was obtained with the bovie and the spermatic cord was identified.  it was clamped, suture ligated with 0 chromic catgut and the cord above was infiltrated with 0.25% marcaine for postoperative pain relief.  the left testicle was delivered through the same incision.  the spermatic cord was identified, clamped, suture ligated and that cord was also injected with 0.25% percent marcaine.  the incision was injected with the same material and then closed in two layers using 4-0 chromic catgut continuous for the dartos and interrupted for the skin.  a dry sterile dressing fluff and scrotal support applied over that.  the patient was sent to the recovery room in stable condition.",37
"chief complaint:,  vomiting and nausea.,hpi: , the patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.  she states she has it at least once a day.  it can be any time, but can also be postprandial.  she states she will vomit up some dark brown-to-green fluid.  there has been no hematemesis.  she states because of the nausea and vomiting, she has not been able to take much in the way of po intake over the past week.  she states her appetite is poor.  the patient has lost 40 pounds of weight over the past 16 months.  she states for the past few days, she has been getting severe heartburn.  she used tums over-the-counter and that did not help.  she denies having any dysphagia or odynophagia.  she is not having any abdominal pain.  she has no diarrhea, rectal bleeding, or melena.  she has had in the past, which was remote.  she did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool.  she has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged.  the patient states she has never had any endoscopy or barium studies of the gi tract.,the patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34.  she states she has had these abnormalities since she has been diagnosed with breast cancer.  she states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist.  the patient also has acute renal failure at this point.  the patient said she had a pet scan done about a week ago.,past medical history:,  metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,allergies: , no known drug allergies.,medicines:,  she is on zofran, protonix, fentanyl patch, synthroid, ativan, and ambien.,social history:  ,the patient is divorced and is a homemaker.  no smoking or alcohol.,family history:,  negative for any colon cancer or polyps.  her father died of mesothelioma, mother died of hodgkin lymphoma.,systems review: , no fevers, chills or sweats.  she has no chest pain, palpitations, coughing or wheezing.  she does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders.  the rest of the system review is negative as per the hpi.,physical exam: , temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg.  general appearance:  the patient was comfortable in bed.  skin exam is negative for any rashes or jaundice.  lymphatics:  there is no palpable lymphadenopathy of the cervical or the supraclavicular area.  heent:  she has some mild ptosis of the right eye.  there is no icterus.  the patient's conjunctivae and sclerae are normal.  pupils are equal, round, and reactive to light and accommodation.  no lesions of the oral mucosa or mucosa of the pharynx.  neck:  supple.  carotids are 2+.  no thyromegaly, masses or adenopathy.  heart:  has regular rhythm.  normal s1 and s2.  she has a 2/6 systolic ejection murmur.  no rubs or gallops.  lungs are clear to percussion and auscultation.  abdomen is obese, it may be mildly distended.  there is no increased tympany.  the patient does have hepatosplenomegaly.  there is no obvious evidence of ascites.  the abdomen is nontender, bowel sounds are present.  the extremities show some swelling and edema of the ankle regions bilaterally.  legs are in scds.  no cyanosis or clubbing.  for the rectal exam, it shows brown stool that is very trace heme positive at most.  for the neuro exam, she is awake, alert, and oriented x3.  memory intact.  no focal deficits.  insight and judgment are intact.,x-ray and laboratory data:  ,she came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, mcv of 87, platelet count is 47,000.  calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, bun of 69, creatinine of 5.2, albumin 2.2, alt 28, bilirubin is 2.2, alkaline phosphatase is 359, ast is 96, and lipase is 30.  today, her hemoglobin is 5.7, tsh is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,impression,1.  the patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration.  this could be on the basis of her renal failure.  she may have a viral gastritis.  the patient does have a lot of gastroesophageal reflux disease symptoms recently.  she could have peptic mucosal inflammation or peptic ulcer disease.,2.  the patient does have hepatosplenomegaly.  there is a possibility she could have liver metastasis from the breast cancer.,3.  she has anemia as well as thrombocytopenia.  the patient states this is chronic.,4.  a 40-pound weight loss.,5.  metastatic breast cancer.,6.  increased liver function tests.  given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7.  chronic constipation.,8.  acute renal failure.,plan:  ,the patient will be on a clear liquid diet.  she will continue on the zofran.  she will be on iv protonix.  the patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored.  i obtained the result of the abdominal x-rays she had done through the er.  the patient has a consult pending with the oncologist to see what her pet scan show.  there is a renal consult pending.  i am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys.  her laboratory studies will be followed.  based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about egd versus upper gi workup per upper gi symptoms.  i discussed informed consent for egd.  i discussed the indications, risks, benefits, and alternatives.  the risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery.  the patient voices her understanding of the above.  she wants to think about what she wants to do.  overall, this is a very ill patient with multiorgan involvement.",14
"exam: , right foot series.,reason for exam:  ,injury.,findings: , three images of the right foot were obtained.  on the ap image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  fractures in these bones cannot be completely excluded.  there is soft tissue swelling seen overlying the calcaneus within this region.,impression: , cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  recommend correlation with site of pain in addition to conservative management and followup imaging.  a phone call will be placed to the emergency room regarding these findings.",31
"child physical examination,vital signs:  birth weight is ** grams, length **, occipitofrontal circumference **.  character of cry was lusty.,general appearance:  well.,breathing:  unlabored.,skin:  clear.  no cyanosis, pallor, or icterus.  subcutaneous tissue is ample.,head:  normal.  fontanelles are soft and flat.  sutures are opposed.,eyes:  normal with red reflex x2.,ears:  patent.  normal pinnae, canals, tms.,nose:  patent nares.,mouth:  no cleft.,throat:  clear.,neck:  no masses.,chest:  normal clavicles.,lungs:  clear bilaterally.,heart:  regular rate and rhythm without murmur.,abdomen:  soft, flat.  no hepatosplenomegaly.  the cord is three vessel.,genitalia:  normal ** genitalia **with testes descended bilaterally.,anus:  patent.,spine:  straight and without deformity.,extremities:  equal movements.,muscle tone:  good.,reflexes:  moro, grasp, and suck are normal.,hips:  no click or clunk.",14
"ears, nose, mouth and throat: , the nose is without any evidence of any deformity.  the ears are with normal-appearing pinna.  examination of the canals is normal appearing bilaterally.  there is no drainage or erythema noted.  the tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  hearing is grossly intact to finger rubbing and whisper.  the nasal mucosa is moist.  the septum is midline.  there is no evidence of septal hematoma.  the turbinates are without abnormality.  no obvious abnormalities to the lips.  the teeth are unremarkable.  the gingivae are without any obvious evidence of infection.  the oral mucosa is moist and pink.  there are no obvious masses to the hard or soft palate.  the uvula is midline.  the salivary glands appear unremarkable.  the tongue is midline.  the posterior pharynx is without erythema or exudate.  the tonsils are normal appearing.",14
"doctor's address,dear doctor:,this letter serves as a reintroduction of my patient, a, who will be seeing you on thursday, 06/12/2008.  as you know, he is an unfortunate gentleman who has reflex sympathetic dystrophy of both lower extremities.  his current symptoms are more severe on the right and he has had a persisting wound that has failed to heal on his right leg.  he has been through wound clinic to try to help heal this, but was intolerant of compression dressings and was unable to get satisfactory healing of this.  he has been seen by dr. x for his pain management and was considered for the possibility of amputation being a therapeutic option to help reduce his pain.  he was seen by dr. y at orthopedic associates for review of this.  however, in my discussion with dr. z and his evaluation of mr. a, it was felt that this may be an imprudent path to take given the lack of likelihood of reduction of his pain from his rst, his questionable healing of his wound given noninvasive studies that did reveal tenuous oxygenation of the right lower leg, and concerns of worsening of his rst symptoms on his left leg if he would have an amputation.  based on the results of his transcutaneous oxygen levels and his dramatic improvement with oxygen therapy at this test, dr. z felt that a course of hyperbaric oxygen may be of utility to help in improving his wounds.  as you may or may not know we have certainly pursued aggressive significant measures to try to improve mr. a's pain.  he has been to cleveland clinic for implantable stimulator, which was unsuccessful at dramatically improving his pain.  he currently is taking methadone up to eight tablets four times a day, morphine up to 100 mg three times a day, and dilaudid two tablets by mouth every two hours to help reduce his pain.  he also is currently taking neurontin 1600 mg three times a day, effexor xr 250 mg once a day, cytomel 25 mcg once a day, seroquel 100 mg p.o. q. day, levothyroxine 300 mcg p.o. q. day, prinivil 20 mg p.o. q. day, and mevacor 40 mg p.o. q day.,i appreciate your assistance in determining if hyperbaric oxygen is a reasonable treatment course for this unfortunate situation.  dr. z and i have both tried to stress the fact that amputation may be an abrupt and irreversible treatment course that may not reach any significant conclusion.  he has been evaluated by dr. x for rehab concerns to determine.  he agrees that a less aggressive form of therapy may be most appropriate.,i thank you kindly for your prompt evaluation of this kind gentleman in an unfortunate situation.  if you have any questions regarding his care please feel free to call me at my office.  otherwise, i look forward to hearing back from you shortly after your evaluation.  please feel free to call me if it is possible or if you have any questions about anything.",18
"preoperative diagnosis: , radioactive plaque macular edema.,postoperative diagnosis:,  radioactive plaque macular edema.,title of operation:,  removal of radioactive plaque, right eye with lateral canthotomy.,operative procedure in detail: , the patient was prepped and draped in the usual manner for a local eye procedure.  then a retrobulbar injection of 2% xylocaine was performed.  a lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  a 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.  next, the plaque was identified and the two scleral sutures were removed.  the plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture.  the fundus was inspected with direct ophthalmoscopy.  an eye patch was applied following neosporin solution irrigation.  the patient was sent to the recovery room in good condition.  a lateral canthotomy had been done.",36
"history of present illness: , patient is a 14-year-old white female who presents with her mother complaining of a four-day history of cold symptoms consisting of nasal congestion and left ear pain.  she has had a dry cough and a fever as high as 100, but this has not been since the first day.  she denies any vomiting or diarrhea.  she did try some tylenol cough and cold followed by tylenol cough and cold severe, but she does not think that this has helped.,family history: , the patient's younger sister has recently had respiratory infection complicated by pneumonia and otitis media.,review of systems:,  the patient does note some pressure in her sinuses.  she denies any skin rash.,social history:,  patient lives with her mother, who is here with her.,nursing notes were reviewed with which i agree.,physical examination,vital signs:  temp is 38.1, pulse is elevated at 101, other vital signs are all within normal limits.  room air oximetry is 100%.,general:  patient is a healthy-appearing, white female, adolescent who is sitting on the stretcher, and appears only mildly ill.,heent:  head is normocephalic, atraumatic.  pharynx shows no erythema, tonsillar edema, or exudate.  both tms are easily visualized and are clear with good light reflex and no erythema.  sinuses do show some mild tenderness to percussion.,neck:  no meningismus or enlarged anterior/posterior cervical lymph nodes.,heart:  regular rate and rhythm without murmurs, rubs, or gallops.,lungs:  clear without rales, rhonchi, or wheezes.,skin:  no rash.,assessment:,  viral upper respiratory infection (uri) with sinus and eustachian congestion.,plan:,  i did educate the patient about her problem and urged her to switch to advil cold & sinus for the next three to five days for better control of her sinus and eustachian discomfort.  i did urge her to use afrin nasal spray for the next three to five days to further decongest her sinuses.  if she is unimproved in five days, follow up with her pcp for re-exam.",10
"preoperative diagnoses:,  ,1.  spondylosis with cervical stenosis c5-c6 greater than c4-c5, c6-c7, (721.0, 723.0).,2.  neck pain with left radiculopathy, progressive (723.1/723.4).,3.  headaches, progressive (784.0).,postoperative diagnoses:,  ,1.  spondylosis with cervical stenosis c5-c6 greater than c4-c5, c6-c7, (721.0, 723.0).,2.  neck pain with left radiculopathy, progressive (723.1/723.4).,3.  headaches, progressive (784.0).,procedures:,  ,1.  anterior cervical discectomy at c5-c6 for neural decompression (63075).,2.  anterior interbody fusion c5-c6 (22554) utilizing bengal cage (22851).,3.  anterior cervical instrumentation at c5-c6 for stabilization by uniplate construction at c5-c6 (22845); with intraoperative x-ray x2.,service:  ,  neurosurgery,anesthesia:,",25
"ct abdomen without contrast and ct pelvis without contrast,reason for exam: , evaluate for retroperitoneal hematoma, the patient has been following, is currently on coumadin.,ct abdomen: , there is no evidence for a retroperitoneal hematoma.,the liver, spleen, adrenal glands, and pancreas are unremarkable.  within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  a 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  no calcifications are noted.  the kidneys are small bilaterally.,ct pelvis: , evaluation of the bladder is limited due to the presence of a foley catheter, the bladder is nondistended.  the large and small bowels are normal in course and caliber.  there is no obstruction.,bibasilar pleural effusions are noted.,impression:,1. no evidence for retroperitoneal bleed.,2. there are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. the kidneys are small in size bilaterally.,4. bibasilar pleural effusions.",13
"protocol:,  bruce.,pertinent medication: , none.,reason for test:,  chest pain.,procedure and interpretation: ,1.  baseline heart rate:  67.,2.  baseline blood pressure:  150/86.,3.  total time:  6 minute 51 seconds.,4.  mets:  10.1.,5.  peak heart rate:  140.,6.  percent of maximum-predicted heart rate:  90.,7.  peak blood pressure:  200/92.,8.  reason test terminated:  shortness of breath and fatigue.,9.  estimated aerobic capacity:  average.,10. heart rate response:  normal.,11. blood pressure response:  hypertensive.,12. st segment response:  normal.,13. chest pain:  none.,14. symptoms:  none.,15. arrhythmia:  none.,conclusion:,1.  average aerobic capacity.,2.  normal heart rate and blood pressure response to exercise.,3.  no symptomatic electrocardiographic evidence of ischemia.,condition: , stable with normal vital signs.,disposition:  ,the patient was discharged home and was asymptomatic.,",2
"chief complaint:,1.  metastatic breast cancer.,2.  enrolled is clinical trial c40502.,3.  sinus pain.,history of present illness: , she is a very pleasant 59-year-old nurse with a history of breast cancer.  she was initially diagnosed in june 1994.  her previous treatments included zometa, faslodex, and aromasin.  she was found to have disease progression first noted by rising tumor markers.  pet/ct scan revealed metastatic disease and she was enrolled in clinical trial of ctsu/c40502.  she was randomized to the ixabepilone plus avastin.  she experienced dose-limiting toxicity with the fourth cycle.  the ixempra was skipped on day 1 and day 8.  she then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  early in the month she had concerned about possible perforated septum.  she was seen by ent urgently.  she was found to have nasal septum intact.  she comes into clinic today for day eight ixempra.,current medications:  ,zometa monthly, calcium with vitamin d q.d., multivitamin q.d., ambien 5 mg q.h.s., pepcid ac 20 mg q.d., effexor 112 mg q.d., lyrica 100 mg at bedtime, tylenol p.r.n., ultram p.r.n., mucinex one to two tablets b.i.d., neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,allergies:  ,compazine.,review of systems: , the patient is comfort in knowing that she does not have a septal perforation.  she has progressive neuropathy and decreased sensation in her fingertips.  she makes many errors when keyboarding.  i would rate her neuropathy as grade 2.  she continues to have headaches respond to ultram which she takes as needed.  she occasionally reports pain in her right upper quadrant as well as right sternum.  he denies any fevers, chills, or night sweats.  her diarrhea has finally resolved and her bowels are back to normal.  the rest of her review of systems is negative.,physical exam:,vitals:",33
"preoperative diagnosis: , ruptured globe ox.,postoperative diagnosis:,  ruptured globe ox.,procedure: , repair of ruptured globe ox.,anesthesia:, general,specimens:,  none.,complications: ,none.,indications:, this is a xx-year-old (wo)man with a ruptured globe of the xxx eye.,procedure:, the risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. informed consent was obtained. the patient received iv antibiotics including ancef and levaeuin prior to surgery. the patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. a wire lid speculum was placed to provide exposure.,upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. the rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. there was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. there was a large blood clot filling the anterior chamber. an attempt was made to wash out the anterior chamber with bss on a cannula. the bss was injected through the limbal rupture, which communicated with the anterior chamber. the blood clot did not move. it was extremely adherent to the iris.,at that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. the scleral laceration was then closed using 10 interrupted sutures with 9-0 vicryl. at that time, the anterior chamber was formed and appeared to be fairly deep. the wounds were checked and found to be watertight. the knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 vicryl sutures, 2 nasally and 2 temporally. all suture knots were buried.  ,gentamicin 0.5 cc was injected subconjunctivally. then, the speculum was removed. the drapes were removed. several drops of ocuflox and maxitrol ointment were placed in the xxx eye. an eye patch and shield were placed over the eye. the patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.",24
"preoperative diagnoses:,1.  epidural hematoma, cervical spine.,2.  status post cervical laminectomy, c3 through c7 postop day #10.,3.  central cord syndrome.,4.  acute quadriplegia.,postoperative diagnoses:,1.  epidural hematoma, cervical spine.,2.  status post cervical laminectomy, c3 through c7 postop day #10.,3.  central cord syndrome.,4.  acute quadriplegia.,procedure performed:,1.  evacuation of epidural hematoma.,2.  insertion of epidural drain.,anesthesia: , general.,complications:  ,none.,estimated blood loss:  ,200 cc.,history:  ,this is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in maryland in april of 2003 after having myocardial infarction.  she was then transferred to beaumont hospital, at which point, she developed a sternal abscess.  the patient was treated for the abscess in beaumont and then subsequently transferred to some other type of facility near her home in warren, michigan at which point, she developed a second what was termed minor myocardial infarction.,the patient subsequently recovered in a cardiac rehab facility and approximately two weeks later, brings us to the month of august, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an mri, which showed record signal change.  the patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  when she examined the patient, she also noted that the patient was unable to move her extremities.  she was concerned and called the orthopedic resident who identified the patient to be truly quadriplegic.  i was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  on clinical examination, there was swelling in the posterior aspect of the neck.  the patient has no active movement in the upper and lower extremity muscle groups.  reflexes are absent in the upper and lower extremities.  long track signs are absent.  sensory level is at the c4 dermatome.  rectal tone is absent.  i discussed the findings with the patient and also the daughter.  we discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  they are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,operative procedure:  ,the patient was taken to or #1 at abcd general hospital on a gurney.  department of anesthesia administered fiberoptic intubation and general anesthetic.  a foley catheter was placed in the bladder.  the patient was log rolled in a prone position on the jackson table.  bony prominences were well padded.  the patient's head was placed in the prone view anesthesia head holder.  at this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  next, the patient was prepped and draped in the usual sterile fashion.  the previous skin incision was reopened.  at this point, hematoma properly exits from the wound.  all sutures were removed and the epidural spaces were encountered at this time.  the self-retaining retractors were placed in the depth of the wound.  consolidated hematoma was now removed from the wound.  next, the epidural space was encountered.  there was no additional hematoma in the epidural space or on the thecal sac.  a curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  the inferior edge of the c2 lamina was explored and there was no compression at this level and the superior lamina of t1 was explored and again no compression was identified at this area as well.  next, the wound was irrigated copiously with one liter of saline using a syringe.  the walls of the wound were explored.  there was no active bleeding.  retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  a #19 french hemovac drain was passed percutaneously at this point and placed into the epidural space.  fascia was reapproximated with #1 vicryl sutures, subcutaneous tissue with #3-0 vicryl sutures.  steri-strips covered the incision and dressing was then applied over the incision.  the patient was then log rolled in the supine position on the hospital gurney.  she remained intubated for airway precautions and transferred to the recovery room in stable condition.  once in the recovery room, she was alert.  she was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  prognosis for this patient is guarded.",21
"preoperative diagnosis: , severe degenerative joint disease of the right shoulder.,postoperative diagnosis:,  severe degenerative joint disease of the right shoulder.,procedure: , right shoulder hemi-resurfacing using a size 5 biomet copeland humeral head component, noncemented.,anesthesia: , general endotracheal.,estimated blood loss: , less than 100 ml.,complications:,  none.  the patient was taken to postanesthesia care unit in stable condition.  the patient tolerated the procedure well.,indications: , the patient is a 55-year-old female who has had increased pain in to her right shoulder.  x-rays as well as an mri showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  she had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  all risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  the patient still wanted to proceed forward with surgical intervention.  the patient did receive 1 g of ancef preoperatively.,procedure: , the patient was taken to the operating suite, placed in supine position on the operating table.  the department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  the patient was moved to a beach chair position.  all extremities were well padded.  her head was well padded to the table.  her right upper extremity was draped in sterile fashion.  a saber incision was made from the coracoid down to the axilla.  skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  subscapularis tendon was released.  the humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  the glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  a sizer was placed.  it was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  this was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  all extra osteophytes were excised.  the supraspinatus and infraspinatus tendons were intact.  next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  the arm had excellent range of motion.  there are no signs of gross dislocation.  drill holes were made into the humeral head after which a size 5 copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  excess bone that had been reamed was placed into the copeland metal component, after which this was tapped into position.  after which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  there was no gross sign of dislocation.  wound site once again it was copiously irrigated with saline antibiotics.  the subscapularis tendon was approximated back into position with #2 ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  after which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 vicryl.  the skin was closed with staples.  a sterile dressing was placed.  the patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.",36
"exam: , coronary artery cta with calcium scoring and cardiac function.,history: , chest pain.,technique and findings: , coronary artery cta was performed on a siemens dual-source ct scanner.  post-processing on a vitrea workstation.  150 ml ultravist 370 was utilized as the intravenous contrast agent.  patient did receive nitroglycerin sublingually prior to the contrast.,history: , significant for high cholesterol, overweight, chest pain, family history,patient's total calcium score (agatston) is 10. his places the patient just below the 75th percentile for age.,the lad has a moderate area of stenosis in its midportion due to a focal calcified plaque.  the distal lad was unreadable while the proximal was normal.  the mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  the circumflex is diminutive in size along its proximal portion.  distal is not readable.,cardiac wall motion within normal limits.  no gross pulmonary artery abnormality however they are not well delineated.  a full report was placed on the patient's chart.  report was saved to pacs.",31
"procedures performed:,1.  left heart catheterization.,2.  bilateral selective coronary angiography.,3.  left ventriculography.,4.  right heart catheterization.,indication: , positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,procedure: , after risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  the patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  once adequate anesthesia has been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right femoral artery.  a steel guidewire was inserted through the needle into the vascular lumen without resistance.  a small nick was then made in the skin.  the pressure was held.  the needle was removed over the guidewire.  next, a #6 french arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  the guidewire and dilator were then removed.  the sheath was flushed.  next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  the catheter was then guided into the left ventricle.  the guidewire and dilator were then removed.  the catheter was then flushed.  lvedp was measured and found to be favorable for a left ventriculogram.  the left ventriculogram was performed in the rao position with a single power injection of nonionic contrast material.  lvedp was then remeasured.  pullback was performed, which failed to reveal an lvao gradient.  the catheter was then removed.  next, a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the left main coronary was unable to be engaged with this catheter.  thus it was removed over a guidewire.  next, a judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  left main coronary artery was then engaged.  using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  the catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  next, a judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  the catheter was then removed from the ostium of the right coronary artery and then removed.  the sheath was then flushed.  because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  thus an #18 gauge argon needle was used to cannulate the right femoral vein.  a steel guidewire was inserted through the needle into the vascular lumen.  the needle was removed over the guidewire.  next, an #8 french venous sheath was advanced over the guidewire into lumen without resistance.  the guidewire and dilator were then removed.  the sheath was then flushed.  next, a swan-ganz catheter was advanced to the level of 20 cm.  the balloon was inflated.  under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  hemodynamics were measured along the way.  pa saturation, right atrial saturation, femoral artery saturation were all obtained.  once adequate study has been performed, the catheter was then removed.  both sheaths were flushed and found fine.  the patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,findings:,left ventriculogram:  ,there is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  left ventricular end-diastolic pressure was 38 mmhg preinjection and 40 mmhg postinjection.  there is no lvao.  there is no mitral regurgitation.  there is a trileaflet aortic valve noted.,left main coronary artery:  ,the left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  there is no evidence of any hemodynamically significant stenosis.,left anterior descending: , the lad is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  there is a proximal 60% to 70% stenotic lesion.  there was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,circumflex artery:  ,the circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  there is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  the first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  the third obtuse marginal branch is also small.,right coronary artery:  ,the rca is a moderate caliber vessel with minor luminal irregularities throughout.  there is no evidence of any critical disease.  the right coronary artery is the dominant right coronary vessel.,right heart findings:  ,pulmonary artery pressure equals 61/23 with a mean of 44.  pulmonary artery wedge pressure equals 32.  right ventricle pressure equals 65/24.  the right atrial pressure equals to 22.  cardiac output by fick is 4.9.  cardiac index by fick is 2.3.  hand calculated cardiac output equals 7.8.  hand calculated cardiac index equals 3.7.  on 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  femoral artery saturation equals 99.1%.  pulse oximetry is 99%.  right atrial saturation is 76.3%.  systemic blood pressure is 166/58.  body surface area equals 2.12.  hemoglobin equals 12.6.,impression:,1.  two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  normal left ventricular function with an estimated ejection fraction of 60%.,3.  biventricular overload.,4.  moderate pulmonary hypertension.,5.  there is no evidence of shunt.,plan:,1.  the patient will be admitted for iv diuresis in light of the biventricular overload.,2.  the findings of the heart catheterization were discussed in detail with the patient and the patient's family.  there is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  we will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  the patient will remain on aggressive medical regimen including ace inhibitor, aspirin, plavix, and nitrate.,4.  the patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  the patient will have an internal medicine evaluation regarding the patient's diabetic history.",36
"preoperative diagnoses:,1.  hallux abductovalgus deformity, right foot.,2.  tailor bunion deformity, right foot.,postoperative diagnoses:,1.  hallux abductovalgus deformity, right foot.,2.  tailor bunion deformity, right foot.,procedures performed:  ,tailor bunionectomy, right foot, weil-type with screw fixation.,anesthesia: , local with mac, local consisting of 20 ml of 0.5% marcaine plain.,hemostasis:,  pneumatic ankle tourniquet at 200 mmhg.,injectables:,  a 10 ml of 0.5% marcaine plain and 1 ml of dexamethasone phosphate.,material: , a 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm osteomed noncannulated screw.  a 2-0 vicryl, 3-0 vicryl, 4-0 vicryl, and 5-0 nylon.,complications: , none.,specimens: , none.,estimated blood loss:,  minimal.,procedure in detail: , the patient was brought to the operating room and placed on the operating table in the usual supine position.  at this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  the right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  an esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmhg.  attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  the incision was carried deep utilizing both sharp and blunt dissections.  all major neurovascular structures were avoided.  at this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  this was then incised fully exposing the tendon and the abductor hallucis muscle.  this was then resected from his osseous attachments and a small tenotomy was performed.  at this time, a small lateral capsulotomy was also performed.  lateral contractures were once again reevaluated and noted to be grossly reduced.,attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  the periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  a 0.045 inch k-wire was then driven across the first metatarsal head in order to act as an access dye.  the patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  the dorsal arm was made longer than the plantar arm to accommodate for fixation.  at this time, the capital fragment was resected and shifted laterally into a more corrected position.  at this time, three portions of the 0.045-inch k-wire were placed across the osteotomy site in order to access temporary forms of fixation.  two of the three of these k-wires were removed in sequence and following the standard ao technique two 3.4 x 15 mm and one 2.4 x 14 mm osteomed noncannulated screws were placed across the osteotomy site.  compression was noted to be excellent.  all guide wires and 0.045-inch k-wires were then removed.  utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  the wound was then once again flushed with copious amounts of sterile normal saline.  at this time, utilizing both 2-0 and 3-0 vicryl, the periosteal and capsular layers were then reapproximated.  at this time, the skin was then closed in layers utilizing 4-0 vicryl and 4-0 nylon.  at this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,a periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  utilizing the sagittal saw, a weil-type osteotomy was made at the fifth metatarsal head.  the head was then shifted medially into a more corrected position.  a 0.045-inch k-wire was then used as a temporary fixation, and a 2.0 x 10 mm osteomed noncannulated screw was placed across the osteotomy site.  this was noted to be in correct position and compression was noted to be excellent.  utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  the wound was once again flushed with copious amounts of sterile normal saline.  the periosteal and capsular layers were reapproximated utilizing 3-0 vicryl, and the skin was then closed utilizing 4-0 vicryl and 4-0 nylon.  at this time, 10 ml of 0.5% marcaine plain and 1 ml of dexamethasone phosphate were infiltrated about the surgical site.  the right foot was then dressed with xeroform gauze, fluffs, kling, and ace wrap, all applied in mild compressive fashion.  the pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  the patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  after a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with dr. a.  the patient is to be nonweightbearing to the right foot.  the patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  the patient tolerated the procedure and anesthesia well.  dr. a was present throughout the entire case.",25
"flexible bronchoscopy,the flexible bronchoscopy is performed under conscious sedation in the pediatric intensive care unit.  i explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  a bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  the sample will then be sent for testing.  the flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,the parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  a booklet containing the description of the procedure and other information was provided.",27
"procedure performed:,  laparoscopic cholecystectomy with attempted intraoperative cholangiogram.,procedure: , after informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  general endotracheal anesthesia was induced without incident.  the patient was prepped and draped in the usual sterile manner.,a 2 cm infraumbilical midline incision was made.  the fascia was then cleared of subcutaneous tissue using a tonsil clamp.  a 1-2 cm incision was then made in the fascia, gaining entry into the abdominal cavity without incident.  two sutures of 0 vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm hasson trocar fitted with a funnel-shaped adapter in order to occlude the fascial opening.  pneumoperitoneum was then established using carbon dioxide insufflation to a steady pressure of 16 mmhg.,the remaining trocars were then placed into the abdomen under direct vision of the 30 degree laparoscope taking care to make the incisions along langer's lines, spreading the subcutaneous tissues with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  a total of 3 other trocars were placed.  the first was a 10/11 mm trocar in the upper midline position.  the second was a 5 mm trocar placed in the anterior axillary line approximately 3 cm above the anterior superior iliac spine.  the third was a 5 mm trocar placed to bisect the distance between the second and upper midline trocars.  all of the trocars were placed without difficulty.,the patient was then placed in reverse trendelenburg position and was rotated slightly to the left.  the gallbladder was then grasped through the second and third trocars and retracted cephalad toward the right shoulder.  a laparoscopic dissector was then placed through the upper midline cannula, fitted with a reducer, and the structures within the triangle of calot were meticulously dissected free.,a laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic duct close to the gallbladder.  the gallbladder was then grasped through the upper midline cannula and a fine-tipped scissors introduced through the third cannula and used to make a small ductotomy in the cystic duct near the clips.  several attempts at passing the cholangiocatheter into the ductotomy were made.  despite numerous attempts at several angles, the cholangiocatheter could not be inserted into the cystic duct.  after several such attempts, and due to the fact that the anatomy was clear, we aborted any further attempts at cholangiography.  the distal cystic duct was doubly clipped.  the duct was divided between the clips.  the clips were carefully placed to avoid occluding the juncture with the common bile duct.  the port sites were injected with 0.5% marcaine.,the cystic artery was found medially and slightly posteriorly to the cystic duct.  it was carefully dissected free from its surrounding tissues.  a laparoscopic clip applier was introduced through the upper midline cannula and used to doubly ligate the cystic artery proximally and distally.  the artery was divided between the clips.  the port sites were injected with 0.5% marcaine.,after the cystic duct and artery were transected, the gallbladder was dissected from the liver bed using bovie electrocautery.  prior to complete dissection of the gallbladder from the liver, the peritoneal cavity was copiously irrigated with saline and the operative field was examined for persistent blood or bile leaks of which there were none.,after the complete detachment of the gallbladder from the liver, the video laparoscope was removed and placed through the upper 10/11 mm cannula.  the neck of the gallbladder was grasped with a large penetrating forceps placed through the umbilical 12 mm hasson cannula.  as the gallbladder was pulled through the umbilical fascial defect, the entire sheath and forceps were removed from the abdomen.  the neck of the gallbladder was then secured with a kocher clamp, and the gallbladder was removed from the abdomen.,following gallbladder removal, the remaining carbon dioxide was expelled from the abdomen.,both midline fascial defects were then approximated using 0 vicryl suture.  all skin incisions were approximated with 4-0 vicryl in a subcuticular fashion.  the skin was prepped with benzoin, and steri-strips were applied.  dressings were applied.  all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",13
"preoperative diagnosis:  ,esophageal rupture.,postoperative diagnosis:,  esophageal rupture.,operation performed,1.  left thoracotomy with drainage of pleural fluid collection.,2.  esophageal exploration and repair of esophageal perforation.,3.  diagnostic laparoscopy and gastrostomy.,4.  radiographic gastrostomy tube study with gastric contrast, interpretation.,anesthesia: , general anesthesia.,indications of the procedure: , the patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  he has esophageal rupture on ct scan and comes now for a thoracotomy and gastrostomy.,details of the procedure: , after an extensive informed consent discussion process, the patient was brought to the operating room.  he was placed in a supine position on the operating table.  after induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  left chest was prepped and draped in a usual sterile fashion.  after administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  the left lung was deflated and the pleural cavity entered.  the finochietto retractor was used to help provide exposure.  the sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,immediately encountered was left pleural fluid including some purulent fluid.  cultures of this were sampled and sent for microbiology analysis.  the left pleural space was then copiously irrigated.  a careful expiration demonstrated that the rupture appeared to be sealed.  there was crepitus within the mediastinal cavity.  the mediastinum was opened and explored and the esophagus was explored.  the tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  it was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  the area was copiously irrigated, this provided nice coverage and repair.  after final irrigation and inspection, two chest tubes were placed including a #36 french right angled tube at the diaphragm and a posterior straight #36 french.  these were secured at the left axillary line region at the skin level with #0-silk.,the intercostal sutures were used to close the chest wall with a #2 vicryl sutures.  muscle layers were closed with running #1 vicryl sutures.  the wound was irrigated and the skin was closed with skin staples.,the patient was then turned and placed in a supine position.  a laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  a veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  the laparoscope was introduced.  a single additional left-sided separator trocar was introduced.  it was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  the stomach however did have some air insufflation and we were able to place our t-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  the skin incision was made and the gastric lumen was then accessed with the seldinger technique.  guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 french gastrostomy was then passed into the stomach lumen and the balloon was inflated.  we confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  the t-fasteners were all crimped and secured into position.  as was in the plan, the gastrostomy was secured to the skin and into the tube.  sterile dressing was applied.  aspiration demonstrated gastric content.,gastrostomy tube study, with interpretation.  radiographic gastrostomy tube study with gastric contrast, with",13
"s -, a 44-year-old, 250-pound male presents with extreme pain in his left heel.  this is his chief complaint.  he says that he has had this pain for about two weeks.  he works on concrete floors.  he says that in the mornings when he gets up or after sitting, he has extreme pain and great difficulty in walking.  he also has a macular blotching of skin on his arms, face, legs, feet and the rest of his body that he says is a pigment disorder that he has had since he was 17 years old.  he also has redness and infection of the right toes.,o -, the patient apparently has a pigmentation disorder, which may or may not change with time, on his arms, legs and other parts of his body, including his face.  he has an erythematous moccasin-pattern tinea pedis of the plantar aspects of both feet.  he has redness of the right toes 2, 3 and 4.  extreme exquisite pain can be produced by direct pressure on the plantar aspect of his left heel.,a -, 1.  plantar fasciitis.,",33
"cc:, falls.,hx: ,this 51y/o rhf fell four times on 1/3/93, because her ""legs suddenly gave out."" she subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. during some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. during one episode she held her rue in an ""odd fisted posture."" she denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. she did not seek medical attention despite her weakness. then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to uihc for evaluation on 1/5/93.,meds: ,micronase 5mg qd, hctz, quit asa 6 months ago (tired of taking it).,pmh:, 1)dm type 2, dx 6 months ago. 2)htn. 3)djd. 4)s/p vitrectomy and retinal traction ou for retinal detachment 7/92. 5) s/p cholecystemomy,1968. 6) cataract implant, ou,1992. 7) s/p c-section.,fhx: ,grand aunt (stroke), mg (cad), mother (cad, died mi age 63), father (with unknown ca), sisters (htn), no dm in relatives.,shx: ,married, lives with husband, 4 children alive and well. denied tobacco/etoh/illicit drug use.,ros:, intermittent diarrhea for 20 years.,exam: ,bp164/82 hr64 rr18 36.0c,ms: a & o to person, place, time. speech fluent and without dysarthria. intact naming, comprehension, reading.,cn: pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. optic disks flat. eom intact. vfftc. right lower facial weakness. the rest of the cn exam was unremarkable.,motor: 5/5 bue with some question of breakaway. le: hf and he 4+/5, kf5/5, af and ae 5/5. normal muscle bulk and tone.,sensory: intact pp/vib/prop/lt/t/graphesthesia.,coord: slowed fnf and hks (worse on right).,station: no pronator drift or romberg sign.,gait: unsteady wide-based gait. unable to heel walk on right.,reflexes: 2/2+ throughout (slightly more brisk on right). plantar responses were downgoing bilaterally.,heent: n0 carotid or cranial bruits.,gen exam: unremarkable.,course:, cbc, gs (including glucose), pt/ptt, ekg, cxr on admission, 1/5/93, were unremarkable. hct, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. carotid duplex: 0-15%rica, 16-49%lica; antegrade vertebral artery flow, bilaterally. transthoracic echocardiogram showed borderline lv hypertrophy and normal lv function. no valvular abnormalities or thrombus were seen.,the patient's history and exam findings of right facial and rle weakness with sparing of the rue would invoke a raca territory stroke with recurrent artery of heubner involvement causing the facial weakness.",20
"history of present problem:,  xyz was seen by dr. abc for an fcr tendinitis.  we do not have his reports, but by history she has had two cortisone shots.  she plays musical instruments, and it does bother her from time to time.  she was considering surgery, but she takes ibuprofen and it seems to be well-controlled.  she is here now for consultation. ,clinical/physical examination: , ,general:  the patient is alert and oriented times three in no acute distress. ,skin:  no skin breakdown or hyperhidrosis.,vascular:  2+ radial and ulnar artery pulses.,musculoskeletal:  wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the fcr tendon on the scaphoid tubercle, but there is no sl instability and no signs of lunotriquetral instability or midcarpal instability.  the druj is stable.  flexion/extension of the fingers is all intact.  forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.,neurologic:  negative tinel's, phalen's and compression median nerve test.  apb, epl and first dorsal interosseous have 5/5 strength.  forearm, elbow and shoulder exams reveal no neurologic compromise.,gait:  normal.,neck:  negative spurling sign.  negative signs of thoracic outlet.,heent:  pupils equal and reactive with no asymmetry.,clinical impression:,  by history, possible fcr tendinitis.,evaluation/treatment plan:  at this point, we have asked her some questions again.  she is not that sore at this point, and she has had a couple of cortisone shots.  without being the initial treating physician, she has fcr tendinitis that fails to respond to cortisone shots.  she is a candidate for an fcr tunnel release.  it has been described and is effective for those patients with that problem.  my only consideration would be, if the patient should choose, to get an mri when she is symptomatic to confirm the fcr tendinitis.  she will followup with dr. abc as needed or come back to us when she is thinking more along the lines of surgery.",25
"title of operation:,1.  repair of total anomalous pulmonary venous connection.,2.  ligation of patent ductus arteriosus.,3.  repair secundum type atrial septal defect (autologous pericardial patch).,4.  subtotal thymectomy.,5.  insertion of peritoneal dialysis catheter.,indication for surgery: , this neonatal was diagnosed postnatally with total anomalous pulmonary venous connection.  following initial stabilization, she was transferred to the hospital for complete correction.,preop diagnosis:  ,1.  total anomalous pulmonary venous connection.,2.  atrial septal defect.,3.  patent ductus arteriosus.,4.  operative weight less than 4 kilograms (3.2 kilograms).,complications: , none.,cross-clamp time: , 63 minutes.,cardiopulmonary bypass time monitor:,  35 minutes, profound hypothermic circulatory arrest time (4 plus 19) equals 23 minutes.  low flow perfusion 32 minutes.,findings:,  horizontal pulmonary venous confluence with right upper and middle with two veins entering the confluence on the right and multiple entry sites for left-sided veins.  large patulous anastomosis between posterior aspect of the left atrium and anterior aspect of the pulmonary venous confluence.  nonobstructed ascending vein ligated.  patent ductus arteriosus diminutive left atrium with posterior atrial septal defect with deficient inferior margin.  at completion of the procedure, right ventricular pressure approximating one-half of systemic, normal sinus rhythm, good biventricular function by visual inspection.,procedure: , after the informed consent, the patient was brought to the operating room and placed on the operating room table in supine position.  upon induction of general endotracheal anesthesia and placement of indwelling arterial and venous monitoring lines.  the patient was prepped and draped in the usual sterile fashion from chin to groins.  a median sternotomy incision was performed.  dissection was carried through the deeper planes until the sternum was scored and divided with an oscillating saw.  a subtotal thymectomy was performed.  systemic heparinization was achieved and the pericardium was entered and fashioned until cradle.  a small portion of the anterior pericardium was procured and fixed in glutaraldehyde for patch closure of segment of the atrial septal defect during the procedure.  pursestrings were deployed on the ascending aorta on the right.  atrial appendage.  the aorta was then cannulated with an 8-french aorta cannula and the right atrium with an 18-french polystan right-angle cannula.  with an act greater than 400, greater pulmonary bypass was commenced with excellent cardiac decompression and the patent ductus arteriosus was ligated with a 2-0 silk tie.  systemic cooling was started and the head was packed  and iced and systemic steroids were administered.  during cooling, traction suture was placed in the apex of the left ventricle.  after 25 minutes of cooling, the aorta was cross-clamped and the heart arrested by administration of 30 cubic centimeter/kilogram of cold-blood cardioplegia delivered directly within the aortic root following the aorta cross-clamping.  following successful cardioplegic arrest, a period of low flow perfusion was started and a 10-french catheter was inserted into the right atrial appendage substituting the 18-french polystan venous cannula.  the heart was then rotated to the right side and the venous confluence was exposed.  it was incised and enlarged and a corresponding incision in the dorsal and posterior aspect of the left atrium was performed.  the two openings were then anastomosed in an end-to-side fashion with several interlocking sutures to avoid pursestring effect with a running 7-0 pds suture.  following completion of the anastomosis, the heart was returned into the chest and the patient's blood volume was drained into the reservoir.  a right atriotomy was then performed during the period of circulatory arrest.  the atrial septal defect was very difficult to expose, but it was sealed with an autologous pericardial patch was secured in place with a running 6-0 prolene suture.  the usual deairing maneuvers were carried out and lining was administered and the right atriotomy was closed in two layers with a running 6-0 prolene sutures.  the venous cannula was reinserted.  cardiopulmonary bypass restarted and the aorta cross-clamp was released.  the patient returned to normal sinus rhythm spontaneously and started regaining satisfactory hemodynamics which, following a prolonged period of rewarming, allow for us to wean her from cardiopulmonary bypass successfully and moderate inotropic support and sinus rhythm.  modified ultrafiltration was carried out and two sets of atrial and ventricular pacing wires were placed as well as the peritoneal dialysis catheter and two 15-french blake drains.  venous decannulation was followed by aortic decannulation and administration of protamine sulfate.  all cannulation sites were oversewn with 6-0 prolene sutures and the anastomotic sites noticed to be hemostatic.  with good hemodynamics and hemostasis, the sternum was then smeared with vancomycin, placing closure with stainless steel wires.  the subcutaneous tissues were closed in layers with the reabsorbable monofilament sutures.  sponge and needle counts were correct times 2 at the end of the procedure.  the patient was transferred in very stable condition to the pediatric intensive care unit .,i was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.  given the magnitude of the operation, the unavailability of an appropriate level, cardiac surgical resident, mrs. x (attending pediatric cardiac surgery at the hospital) participated during the cross-clamp time of the procedure in quality of first assistant.",27
"male physical examination,eye:  eyelids normal color, no edema.  conjunctivae with no erythema, foreign body, or lacerations.  sclerae normal white color, no jaundice.  cornea clear without lesions.  pupils equally responsive to light.  iris normal color, no lesions.  anterior chamber clear.  lacrimal ducts normal.  fundi clear.,ear:  external ear has no erythema, edema, or lesions.  ear canal unobstructed without edema, discharge, or lesions.  tympanic membranes clear with normal light reflex.  no middle ear effusions.,nose:  external nose symmetrical.  no skin lesions.  nares open and free of lesions.  turbinates normal color, size and shape.  mucus clear.  no internal lesions.,throat:  no erythema or exudates.  buccal mucosa clear.  lips normal color without lesions.  tongue normal shape and color without lesion.  hard and soft palate normal color without lesions.  teeth show no remarkable features.  no adenopathy.  tonsils normal shape and size.  uvula normal shape and color.,neck:  skin has no lesions.  neck symmetrical.  no adenopathy, thyromegaly, or masses.  normal range of motion, nontender.  trachea midline.,chest:  symmetrical.  clear to auscultation bilaterally.  no wheezing, rales or rhonchi.  chest nontender.  normal lung excursion.  no accessory muscle use.,cardiovascular:  heart has regular rate and rhythm with no s3 or s4.  heart rate is normal.,abdominal:  soft, nontender, nondistended, bowel sounds present.  no hepatomegaly, splenomegaly, masses, or bruits.,genital:  penis normal shape without lesions.  testicles normal shape and contour without tenderness.  epididymides normal shape and contour without tenderness.  rectum normal tone to sphincter.  prostate normal shape and contour without nodules.  stool hemoccult negative.  no external hemorrhoids.  no skin lesions.,musculoskeletal:  normal strength all muscle groups.  normal range of motion all joints.  no joint effusions.  joints normal shape and contour.  no muscle masses.,foot:  no erythema.  no edema.  normal range of motion all joints in the foot.  nontender.  no pain with inversion, eversion, plantar or dorsiflexion.,ankle:  anterior and posterior drawer test negative.  no pain with inversion, eversion, dorsiflexion, or plantar flexion.  collateral ligaments intact.  no joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,knee:  normal range of motion.  no joint effusion, erythema, nontender.  anterior and posterior drawer tests negative.  lachman's test negative.  collateral ligaments intact.  bursas nontender without edema.,wrist:  normal range of motion.  no edema or effusion, nontender.  negative tinel and phalen tests.  normal strength all muscle groups.,elbow:  normal range of motion.  no joint effusion or erythema.  normal strength all muscle groups.  nontender.  olecranon bursa flat and nontender, no edema.  normal supination and pronation of forearm.  no crepitus.,hip:  negative swinging test.  trochanteric bursa nontender.  normal range of motion.  normal strength all muscle groups.  no pain with eversion and inversion.  no crepitus.  normal gait.,psychiatric:  alert and oriented times four.  no delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  affect is appropriate.  no psychomotor slowing or agitation.  eye contact is appropriate.",4
"title of operation:,1.  open reduction internal fixation (orif) with irrigation and debridement of open fracture including skin, muscle, and bone using a synthes 3.5 mm locking plate on the lateral malleolus and two synthes 4.5 mm cannulated screws medial malleolus.,2.  closed reduction and screw fixation of right femoral neck fracture using one striker asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  retrograde femoral nail using a striker t2 retrograde nail 10 x 340 with a 10 mm incap and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  irrigation and debridement of right knee.,5.  irrigation and debridement of right elbow abrasions.,preop diagnosis:,1.  right open ankle fracture.,2.  right femoral shaft fracture.,3.  right femoral neck fracture.,4.  right open knee.,5.  right elbow abrasions.,postop diagnosis:,1.  right open ankle fracture.,2.  right femoral shaft fracture.,3.  right femoral neck fracture.,4.  right open knee.,5.  right elbow abrasions.,intravenous fluids: , 650 packed red blood cells.,tourniquet time: , 2 hours.,urine output:  ,1600 cubic centimeters.,estimated blood loss: , 250 cubic centimeters.,complications:,  none.,plan:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,operative narrative:,  the patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  she sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  the risks of surgery were discussed in detail and the consents were signed.  the operative site was marked.  the patient was taken to the operating room where she was given preoperative clindamycin.  the patient had then general anesthetic performed by anesthesia.,a well-padded side tourniquet was placed.  attention was turned to the right ankle first.  the large medical laceration was extended and the tissues were debrided.  all dirty of the all injured bone, muscle, and tissues were debrided.  wound was then copiously irrigated with 8 liters of normal saline.  at this point, the medial malleolus fracture was identified and was reduced.  this was then fixed in with two 4.5 mm cannulated synthes screws.,next, the attention was turned to lateral malleolus.  incision was made over the distal fibula.  it was carried down sharply through the skin in the subcutaneous issues.  care was taken to preserve the superficial peroneal nerve.  the fracture was identified, and there was noted to be very comminuted distal fibula fracture.  the fracture was reduced and confirmed with fluoroscopy.  a 7 hole synthes 3.5 mm locking plate was placed.  this was placed in a bridging fashion with three screws above and three screws below the fracture.  appropriate reduction was confirmed under fluoroscopy.  a cotton test was performed, and the ankle did not open up.  therefore, it was decided not to proceed with syndesmotic screw.,next, the patient was then placed in the fracture table and all extremities were well padded.  all prominences were padded.  the right leg was then prepped and draped in usual sterile fashion.  a 2-cm incision was made just distal to the greater trochanter.  this was carried down sharply through the skin to the fascia.  the femur was identified.  the guidewire for a striker asnis 6.5 mm screw was placed in the appropriate position.  the triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  a reduction of the fracture was performed prior to placing all the guide wires.  a single 8 mm asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,next, the abrasions on the right elbow were copiously irrigated.  the necrotic and dead tissue was removed.  the abrasions did not appear to enter the joints.  they were wrapped with xeroform 4 x 4 x 4 kerlix and ace wrap.,next, the lacerations of the anterior knee were connected and were extended in the midline.  they were carried down sharply to the skin and the retinacular issues to the joint.  the intercondylar notch was identified.  a guide wire for the striker t2 retrograde nail was placed and localized with fluoroscopy.  the opening reamer was used following the bolted guide wire was then passed.  the femur was then sequentially reamed using the flexible reamers.  a t2 retrograde nail 10 x 340 was then passed.  two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,the patient was placed in the ao splints for the right ankle.  the wounds were dressed with xeroform 4 x 4 x 4s and io band.  the care was then transferred for the patient to halstead service.,the plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,dr. x was present and scrubbed for the entirety of the procedure.",36
"preoperative diagnosis: , pilonidal cyst with abscess formation.,postoperative diagnosis:,  pilonidal cyst with abscess formation.,operation: , excision of infected pilonidal cyst.,procedure: , after obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room.  a time-out process was followed.  antibiotics were given and then the patient was prepped and draped in the usual fashion.  it appeared to me that the abscess had drained somewhat during the night, as it was much smaller than i was anticipating.  an elliptical excision of all infected tissues down to the coccyx was performed.  hemostasis was achieved with a cautery.  the wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,the patient was sent to recovery room in satisfactory condition.  estimated blood loss was minimal.  the patient tolerated the procedure well.",15
"history of present illness: , this is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  the patient also reports a 15-pound weight loss.  he denies fever, chills and sweats.  he denies cough and diarrhea.  he has mild anorexia.,past medical history:,  essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  he had a recent ppd which was negative in august 1994.,medications: , none.,allergies: , no known drug allergies.,social history: , he occasionally drinks and is a nonsmoker.  the patient participated in homosexual activity in haiti during 1982 which he described as ""very active."" denies intravenous drug use.  the patient is currently employed.,family history:,  unremarkable.,physical examination:,general:  this is a thin, black cachectic man speaking in full sentences with oxygen.,vital signs:  blood pressure 96/56, heart rate 120.  no change with orthostatics.  temperature 101.6 degrees fahrenheit.  respirations 30.,heent:  funduscopic examination normal.  he has oral thrush.,lymph:  he has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,neck:  no goiter, no jugular venous distention.,chest:  bilateral basilar crackles, and egophony at the right and left middle lung fields.,heart:  regular rate and rhythm, no murmur, rub or gallop.,abdomen:  soft and nontender.,genitourinary:  normal.,rectal:  unremarkable.,skin:  the patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  he has very pale palms., ,laboratory and x-ray data: , sodium 133, potassium 5.3, bun 29, creatinine 1.8.  hemoglobin 14, white count 7100, platelet count 515.  total protein 10, albumin 3.1, ast 131, alt 31.  urinalysis shows 1+ protein, trace blood.  total bilirubin 2.4, direct bilirubin 0.1.  arterial blood gases:  ph 7.46, pc02 32, p02 46 on room air.  electrocardiogram shows normal sinus rhythm.  chest x-ray shows bilateral alveolar and interstitial infiltrates.,impression:,1.  bilateral pneumonia; suspect atypical pneumonia, rule out pneumocystis carinii pneumonia and tuberculosis.,2.  thrush.,3.  elevated unconjugated bilirubins.,4.  hepatitis.,5.  elevated globulin fraction.,6.  renal insufficiency.,7.  subcutaneous nodules.,8.  risky sexual behavior in 1982 in haiti.,plan:,1.  induced sputum, rule out pneumocystis carinii pneumonia and tuberculosis.,2.  begin intravenous bactrim and erythromycin.,3.  begin prednisone.,4.  oxygen.,5.  nystatin swish and swallow.,6.  dermatologic biopsy of lesions.,7.  check hiv and rpr.,8.  administer pneumovax, tetanus shot and heptavax if indicated.",14
"procedure: , eeg during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  the eeg background is symmetric.  independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  no clinical signs of involuntary movements are noted during synchronous video monitoring.  recording time is 22 minutes and 22 seconds.  there is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  no sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  photic stimulation induced a bilaterally symmetric photic driving response.,impression:,  eeg during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  the eeg findings are consistent with potentially epileptogenic process.  clinical correlation is warranted.",34
"preoperative diagnosis:,  rule out temporal arteritis.,postoperative diagnosis:  ,rule out temporal arteritis.,procedure:,  bilateral temporal artery biopsy.,anesthesia:,  local anesthesia 1% xylocaine with epinephrine.,indications:,  i was consulted by dr. x for this patient with bilateral temporal headaches to rule out temporal arteritis.  i explained fully the procedure to the patient.,procedure: , both sides were done exactly the same way.  after 1% xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  the temporal artery was identified and was grossly normal on both sides.  proximal and distal were ligated with both of 3-0 silk suture and hemoccult.  the specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  they were sent as separate specimens, right and left labeled.  the wound was then closed with interrupted 3-0 monocryl subcuticular sutures and dermabond.  she tolerated the procedure well.",20
"postoperative diagnosis:,  chronic adenotonsillitis.,procedure performed: , tonsillectomy and adenoidectomy.,anesthesia:  ,general endotracheal tube.,estimated blood loss:,  minimum, less than 5 cc.,specimens:,  right and left tonsils 2+, adenoid pad 1+.  there was no adenoid specimen.,complications: , none.,history: , the patient is a 9-year-old caucasian male with history of recurrent episodes of adenotonsillitis that has been refractory to outpatient antibiotic therapy.  the patient has had approximately four to five episodes of adenotonsillitis per year for the last three to four years.,procedure: , informed consent was properly obtained from the patient's parents and the patient was taken to the operating room #3 and was placed in a supine position.  he was placed under general endotracheal tube anesthesia by the department of anesthesia.  the bed was then rolled away from department of anesthesia.  a shoulder roll was then placed beneath the shoulder blades and a blue towel was then fashioned as a turban wrap.  the mcivor mouth gag was carefully positioned into the patient's mouth with attention to avoid the teeth.,the retractor was then opened and the oropharynx was visualized.  the adenoid pad was then visualized with a laryngeal mirror.  the adenoids appeared to be 1+ and non-obstructing.  there was no evidence of submucosal cleft palate palpable.  there was no evidence of bifid uvula.  a curved allis clamp was then used to grasp the superior pole of the right tonsil.  the tonsil was then retracted inferiorly and medially.  bovie cautery was used to make an incision on the mucosa of the right anterior tonsillar pillar to find the appropriate plane of dissection.  the tonsil was then dissected out within this plane using a bovie.  tonsillar sponge was re-applied to the tonsillar fossa.  suction cautery was then used to adequately obtain hemostasis with the tonsillar fossa.  attention was then directed to the left tonsil.  the curved allis was used to grasp the superior pole of the left tonsil and it was retracted inferiorly and medially.  bovie cautery was used to make an incision in the mucosa of the left anterior tonsillar pillar and define the appropriate plane of dissection.  the tonsil was then dissected out within this plane using the bovie.  next, complete hemostasis was achieved within the tonsillar fossae using suction cautery.  after adequate hemostasis was obtained, attention was directed towards the adenoid pad.  the adenoid pad was again visualized and appeared 1+ and was non-obstructing.  decision was made to use suction cautery to cauterize the adenoids.  using a laryngeal mirror under direct visualization, the adenoid pad was then cauterized with care to avoid the eustachian tube orifices as well as the soft palate and inferior turbinates.  after cauterization was complete, the nasopharynx was again visualized and tonsillar sponge was applied.  adequate hemostasis was achieved.  the tonsillar fossae were again visualized and no evidence of bleeding was evident.  the throat pack was removed from the oropharynx and the oropharynx was suctioned.  there was no evidence of any further bleeding.  a flexible suction catheter was then used to suction out the nasopharynx to the oropharynx.  the suction catheter was also used to suction up the stomach.  final look revealed no evidence of further bleeding and 10 mg of decadron was given intraoperatively.,disposition:  ,the patient tolerated the procedure well and the patient was transported to the recovery room in stable condition.",10
"preoperative diagnosis: , left mesothelioma, focal.,postoperative diagnosis: , left pleural-based nodule.,procedures performed:,1.  left thoracoscopy.,2.  left mini thoracotomy with resection of left pleural-based mass.,findings:,  left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,fluids: , 800 ml of crystalloid.,estimated blood loss: , minimal.,drains, tubes, catheters: , 24-french chest tube in the left thorax plus foley catheter.,specimens: , left pleural-based nodule.,indication for operation:  ,the patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  preoperative evaluation included a ct scan, which showed focal mass.  ct and pet confirmed anterior lesion.  therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  in the outpatient setting, the patient was willing to proceed.,procedure performed in detail: , after informed consent was obtained, the patient identified correctly.  she was taken to the operating room where an epidural catheter was placed by anesthesia without difficulty.  she was sedated and intubated with double-lumen endotracheal tube without difficulty.  she was positioned with left side up.  appropriate pressure points were padded.  the left chest was prepped and draped in the standard surgical fashion.  the skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and bovie electrocautery.,pleura was entered.  there was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  there were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  the tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  it was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  camera was placed through this port.  laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  this was taken down to the subcutaneous tissue with bovie electrocautery.  periosteal elevator was used to lift the intercostal muscle off.  the ribs were not spread.  through this 3-cm incision, both the laparoscopic scissors as well as prestige graspers could be placed.  prestige graspers were used to pull the specimen from the chest wall.  care was taken not to injure the capsule.  the laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  care was taken not to transect the stalk.  specimen came off the chest wall very easily.  there was good hemostasis.,at this point, the endocatch bag was placed through the incision.  specimen was placed in the bag and then removed from the field.  there was good hemostasis.  camera was removed.  a 24-french chest tube was placed through the anterior port and secured with 2-0 silk suture.  the posterior port site was closed 1st with 2-0 vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 monocryl was used for the skin, followed by steri-strips and sterile drapes.  the patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.",2
"reason for visit:,  the patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by dr. x.,history of present illness: , the patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  it was felt to be stage 2.  it was not n-myc amplified and had favorable shimada histology.  in followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable shimada histology.  he is now being treated with chemotherapy per protocol p9641 and not on study.  he last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  he received g-csf daily after his chemotherapy due to neutropenia that delayed his second cycle.  in the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  he is not acted ill or had any fevers.  he has had somewhat diminished appetite, but it seems to be improving now.  he is peeing and pooping normally and has not had any diarrhea.  he did not have any appreciated nausea or vomiting.  he has been restarted on fluconazole due to having redeveloped thrush recently.,review of systems: , the following systems reviewed and negative per pathology except as noted above.  eyes, ears, throat, cardiovascular, gi, genitourinary, musculoskeletal skin, and neurologic., past medical history:,  reviewed as above and otherwise unchanged.,family history:,  reviewed and unchanged.,social history: , the patient's parents continued to undergo a separation and divorce.  the patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,medications:  ,1.  bactrim 32 mg by mouth twice a day on friday, saturday, and sunday.,2.  g-csf 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  fluconazole 37.5 mg daily.,4.  zofran 1.5 mg every 6 hours as needed for nausea.,allergies: , no known drug allergies.,findings: , a detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  vital signs:  temperature is 35.3 degrees celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmhg.  eyes:  conjunctivae are clear, nonicteric.  pupils are equally round and reactive to light.  extraocular muscle movements appear intact with no strabismus.  ears:  tms are clear bilaterally.  oral mucosa:  no thrush is appreciated.  no mucosal ulcerations or erythema.  chest:  port-a-cath is nonerythematous and nontender to vp access port.  respiratory:  good aeration, clear to auscultation bilaterally.  cardiovascular:  regular rate, normal s1 and s2, no murmurs appreciated.  abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  skin:  no rashes.  neurologic:  the patient walks without assistance, frequently falls on his bottom.,laboratory studies: , cbc and comprehensive metabolic panel were obtained and they are significant for ast 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with anc 2974.  medical tests none.  radiologic studies are none.,assessment: , this patient's disease is life threatening, currently causing moderately severe side effects.,problems diagnoses:  ,1.  neuroblastoma of the right adrenal gland with favorable shimada histology.,2.  history of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  immunosuppression.,4.  mucosal candidiasis.,5.  resolving neutropenia.,procedures and immunizations:,  none.,plans:  ,1.  neuroblastoma.  the patient will return to the pediatric oncology clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  i will plan for restaging with ct of the abdomen prior to the cycle.,2.  immunosuppression.  the patient will continue on his bactrim twice a day on thursday, friday, and saturday.  additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  mucosal candidiasis.  we will continue fluconazole for thrush.  i am pleased that the clinical evidence of disease appears to have resolved.  for resolving neutropenia, i advised gregory's mother about it is okay to discontinue the g-csf at this time.  we will plan for him to resume g-csf after his next chemotherapy and prescription has been sent to the patient's pharmacy.,pediatric oncology attending: , i have reviewed the history of the patient.  this is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of pog-9641 due to his prior history of neutropenia, he has been on g-csf.  his anc is nicely recovered.  he will have a restaging ct prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  he continues on fluconazole for recent history of thrush.  plans are otherwise documented above.",15
"procedure: , colonoscopy.,indications: , hematochezia, personal history of colonic polyps.,medications:,  midazolam 2 mg iv, fentanyl 100 mcg iv,procedure:,  a history and physical has been performed, and patient medication allergies have been reviewed.  the patient's tolerance of previous anesthesia has been reviewed.  the risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  all questions were answered and informed consent was obtained.  mental status examination:  alert and oriented.  airway examination:  normal oropharyngeal airway and neck mobility.  respiratory examination:  clear to auscultation.  cv examination:  rrr, no murmurs, no s3 or s4.  asa grade assessment:  p1 a normal healthy patient.  after reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  the anesthesia plan was to use conscious sedation.  immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  the heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  the physical status of the patient was re-assessed after the procedure.  after i obtained informed consent, the scope was passed under direct vision.  throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  the colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ic valve.  the quality of the prep was good.  the patient tolerated the procedure well.,findings:,1.  a sessile, non-bleeding polyp was found in the rectum.  the polyp was 5 mm in size.  polypectomy was performed with a saline injection-lift technique using the snare.  resection and retrieval were complete.  estimated blood loss was minimal.,2.  one pedunculated, non-bleeding polyp was found in the sigmoid colon.  the polyp was 7 mm in size.  polypectomy was performed with a hot forceps.  resection and retrieval were complete.  estimated blood loss was minimal.,3.  multiple large-mouthed diverticula were found in the descending colon.,4.  internal, non-bleeding, prolapsed with spontaneous reduction (grade ii) hemorrhoids were found on retroflexion.,impression:,1.  one 5 mm benign appearing polyp in the rectum.  resected and retrieved.,2.  one 7 mm polyp in the sigmoid colon.  resected and retrieved.,3.  diverticulosis.,4.  internal hemorrhoids were found.,recommendation:,1.  high fiber diet.,2.  await pathology results.,3.  repeat colonoscopy for surveillance in 3 years.,4.  the findings and recommendations were discussed with the patient.,cpt code(s):,45385, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,icd9 code(s):,211.4, benign neoplasm of rectum and anal canal.,211.3, benign neoplasm of colon.,562.10, diverticulosis of colon (without mention of hemorrhage).,455.2, internal hemorrhoids with other complication,578.1, blood in stool.,v12.72, personal history of colonic polyps.",36
"preoperative diagnosis:,  left masticator space infection secondary to necrotic tooth #17.,postoperative diagnosis: , left masticator space infection secondary to necrotic tooth #17.,surgical procedure:,  extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,fluids:  ,500 ml of crystalloid.,estimated blood loss: , 60 ml.,specimens:,  cultures and sensitivities, aerobic and anaerobic were sent for micro studies.,drains:,  one 0.25-inch penrose placed in the medial aspect of the masticator space.,condition: , good, extubated, breathing spontaneously, to pacu.,indications for procedure:  ,the patient is a 26-year-old caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to clinic, complaining of difficulty swallowing and breathing.  oral surgery was consulted to evaluate the patient.,after evaluation of the facial ct with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17.  risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,description of procedure:,  the patient was transported to operating room #4 at clinic.  he was laid supine on the operating room table.  asa monitors were attached and general anesthesia was induced with iv anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics.  the patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,the surgeon approached the operating room table in sterile fashion.  approximately 2 ml of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision.  after waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 ml of pus was removed.  this was sent for aerobic and anaerobic micro.  using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed.  the left masticator space was thoroughly explored as well as the left submandibular space and submental space.  pus was drained from this site.  copious amounts of sterile fluid were irrigated into the site.,attention was then directed intraorally where a moistened ray-tec sponge was placed in the posterior oropharynx to act as a throat pack.  approximately 4 ml of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block.  using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17.  the tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed.  this pus was evacuated intraorally __________ suction.  the extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,a 0.25-inch penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture.  a tack stitch intraorally with 3-0 chromic suture was placed.  the throat pack was then removed.  an orogastric tube was placed and removed all other stomach contents and then removed.  at this point, the procedure was then determined to be over.  the patient was extubated, breathing spontaneously, and transported to pacu in good condition.",6
"diagnoses:,1.  cervical dystonia.,2.  post cervical laminectomy pain syndrome.,ms. xyz states that the pain has now shifted to the left side.  she has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  she did not have any side effects on the botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  the patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,physical examination:,  the patient is appropriate.  she is well dressed and oriented x3.  she still smells of some cigarette smoke.  examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  there are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  on the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  this extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,treatment plan:,  after a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  a total of 400 units of botox is anticipated.  the procedure is being scheduled.  the patient's medications are refilled.  she will continue to see dr. berry and continue her therapy with mary hotchkinson in victoria.",26
"exam:,  mammographic screening ffdm,history: , 40-year-old female who is on oral contraceptive pills.  she has no present symptomatic complaints.  no prior history of breast surgery nor family history of breast ca.,technique: , standard cc and mlo views of the breasts.,comparison: , this is the patient's baseline study.,findings: , the breasts are composed of moderately to significantly dense fibroglandular tissue.  the overlying skin is unremarkable.,there are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,there are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,there are no spiculated masses or architectural distortion.,impression:,  tiny cluster of calcifications at the 11:30 position of the right breast.  recommend additional views; spot magnification in the mlo and cc views of the right breast.,birads classification 0 - incomplete,mammography information:,1.  a certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  these images were obtained with fda-approved digital mammography equipment, and icad second look software version 7.2 was utilized.",22
"cc:, slowing of motor skills and cognitive function.,hx: ,this 42 y/o lhm presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. he had difficulty holding a job. his most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. for 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). his walk became slower and he had difficulty with balance. he became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. his wife noticed ""fidgety movements"" of his hand and feet.,he was placed on trials of sertraline and fluoxetine for depression 6 months prior to presentation by his local physician. these interventions did not appear to improve his mood and affect.,meds:, fluoxetine.,pmh: ,1)right knee arthroscopic surgery 3 yrs ago. 2)vasectomy.,fhx:, mother died age 60 of complications of huntington disease (dx at uihc). mgm and two ma's also died of huntington disease. his 38 y/o sister has attempted suicide twice.,he and his wife have 2 adopted children.,shx: ,unemployed. 2 years of college education. married 22 years.,ros: ,no history of dopaminergic or antipsychotic medication use.,exam:, vital signs normal.,ms: a&o to person, place, and time. dysarthric speech with poor respiratory control.,cn: occasional hypometric saccades in both horizontal directions. no vertical gaze abnormalities noted. infrequent spontaneous forehead wrinkling and mouth movements. the rest of the cn exam was unremarkable.,motor: full strength throughout and normal muscle tone and bulk. mild choreiform movements were noted in the hands and feet.,sensory: unremarkable.,coord: unremarkable.,station/gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of bue became more apparent.,reflexes: 2/2 throughout. plantar responses were flexor, bilaterally.,there was no motor impersistence on tongue protrusion or hand grip.,course:, he was thought to have early manifestations of huntington disease. a hct was unremarkable. elavil 25mg qhs was prescribed. neuropsychologic assessment revealed mild anterograde memory loss only.,his chorea gradually worsened during the following 4 years. he developed motor impersistence and more prominent slowed saccadic eye movements. his mood/affect became more labile.,6/5/96 genetic testing revealed a 45 cag trinucleotide repeat band consistent with huntington disease. mri brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.",4
"preoperative diagnosis: , basal cell carcinoma, nasal tip, previous positive biopsy.,postoperative diagnosis: , basal cell carcinoma, nasal tip, previous positive biopsy.,operation performed: , excision of nasal tip basal carcinoma.  total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,indication: , a 66-year-old female for excision of nasal basal cell carcinoma.  this area is to be excised accordingly and closed.  we had multiple discussions regarding types of closure.,summary: , the patient was brought to the or in satisfactory condition and placed supine on the or table.  underwent general anesthesia along with marcaine in the nasal tip areas for planned excision.  the area was injected, after sterile prep and drape, with marcaine 0.25% with 1:200,000 adrenaline.,the specimen was sent to pathology.  margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  final margins were clear.,closure consisted of undermining circumferentially.  advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  closure with interrupted 5-0 monocryl running 7-0 nylon followed by xeroform gauze, light pressure dressing, and steri-strips.,the patient is discharged on minocycline and darvocet-n 100.,note:,  the 2.6 mm loupe magnification was utilized throughout the procedure.  no complications noted with excellent and all clear margins at the termination.  an advancement closure technique was utilized.",15
"chief complaint:,  foul-smelling urine and stomach pain after meals.,history of present illness:,  stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  she was prescribed reglan, prilosec, pepcid, and carafate at ed for her gi symptoms and bactrim for uti.  this visit was in july 2010.,review of systems:,  heent:  no headaches.  no visual disturbances, no eye irritation.  no nose drainage or allergic symptoms.  no sore throat or masses.  respiratory:  no shortness of breath.  no cough or wheeze.  no pain.  cardiac:  no palpitations or pain.  gastrointestinal:  pain and cramping.  denies nausea, vomiting, or diarrhea.  has some regurgitation with gas after meals.  genitourinary:  ""smelly"" urine.  musculoskeletal:  no swelling, pain, or numbness.,medication allergies:,  no known drug allergies.,physical examination:,general:  unremarkable.,heent:  perrla.  gaze conjugate.,neck:  no nodes.  no thyromegaly.  no masses.,lungs:  clear.,heart:  regular rate without murmur.,abdomen:  soft, without organomegaly, without guarding or tenderness.,back:  straight.  no paraspinal spasm.,extremities:  full range of motion.  no edema.,neurologic:  cranial nerves ii-xii intact.  deep tendon reflexes 2+ bilaterally.,skin:  unremarkable.,laboratory studies:,  urinalysis was done, which showed blood due to her period and moderate leukocytes.,assessment:,1.  uti.,2.  gerd.,3.  dysphagia.,4.  contraception consult.,plan:,1.  cipro 500 mg b.i.d. x five days.  ordered bmp, cbc, and urinalysis with microscopy.,2.  omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  prescriptions same as #2.  also referred her for a barium swallow series to rule out a stricture.,4.  ortho tri-cyclen lo.,",37
"cc:, left-sided weakness.,hx:, this 28y/o rhm was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. he denied foreign travel, iv drug abuse, homosexuality, recent dental work, or open wound. blood and urine cultures were positive for staphylococcus aureus, oxacillin sensitive. he was place on appropriate antibiotic therapy according to sensitivity.. a 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. later that day he developed left-sided weakness and severe dysarthria and aphasia. hct, on 7/3/95 revealed mild attenuated signal in the right hemisphere. on 7/4/95 he developed first degree av block, and was transferred to uihc.,meds: ,nafcillin 2gm iv q4hrs, rifampin 600mg q12hrs, gentamicin 130mg q12hrs.,pmh:, 1) heart murmur dx age 5 years.,fhx:, unremarkable.,shx:, employed cook. denied etoh/tobacco/illicit drug use.,exam:, bp 123/54, hr 117, rr 16, 37.0c,ms: somnolent and arousable only by shaking and repetitive verbal commands. he could follow simple commands only. he nodded appropriately to questioning most of the time. dysarthric speech with sparse verbal output.,cn: pupils 3/3 decreasing to 2/2 on exposure to light. conjugate gaze preference toward the right. right hemianopia by visual threat testing. optic discs flat and no retinal hemorrhages or roth spots were seen. left lower facial weakness. tongue deviated to the left. weak gag response, bilaterally. weak left corneal response.,motor: dense left flaccid hemiplegia.,sensory: less responsive to pp on left.,coord: unable to test.,station and gait: not tested.,reflexes: 2/3 throughout (more brisk on the left side). left ankle clonus and a left babinski sign were present.,gen exam: holosystolic murmur heard throughout the precordium. janeway lesions were present in the feet and hands. no osler's nodes were seen.,course:, 7/6/95, hct showed a large rmca stroke with mass shift. his neurologic exam worsened and he was intubated, hyperventilated, and given iv mannitol. he then underwent emergent left craniectomy and duraplasty. he tolerated the procedure well and his brain was allowed to swell. he then underwent mitral valve replacement on 7/11/95 with a st. judes valve. his post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. he required temporary peg placement for feeding. the 7/27/95, 8/6/95 and 10/18/96 hct scans show the chronologic neuroradiologic documentation of a large rmca stroke. his 10/18/96 neurosurgery clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. his proximal lle strength was rated at a 4. his lue was plegic. he had a seizure 6 days prior to his 10/18/96 evaluation. this began as a jacksonian march of shaking in the lue; then involved the lle. there was no loc or tongue-biting. he did have urinary incontinence. he was placed on dph. his speech was dysarthric but fluent. he appeared bright, alert and oriented in all spheres.",20
"preoperative diagnoses:,  bilateral inguinal hernia, bilateral hydroceles.,postoperative diagnoses:,  bilateral inguinal hernia, bilateral hydroceles.,procedures: , bilateral inguinal hernia and bilateral hydrocele repair with an ilioinguinal nerve block bilaterally by surgeon 20 ml given.,anesthesia: , general inhalational anesthetic.,abnormal findings:,  same as above.,estimated blood loss: , less than 5 ml.,fluids received: , 400 ml of crystalloid.,drains: , no tubes or drains were used.,count: , sponge and needle counts were correct x2.,indications for procedure:  ,the patient is a 7-year-old boy with the history of fairly sizeable right inguinal hernia and hydrocele, was found to have a second smaller one on evaluation with ultrasound and physical exam.  plan is for repair of both.,description of operation:  ,the patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  once he was anesthetized, he was then placed in a supine position and sterilely prepped and draped.  a right inguinal incision was then made with 15 blade knife and further extended with electrocautery down to the subcutaneous tissue and electrocautery was also used for hemostasis.  the external oblique fascia was then visualized and incised with 15 blade knife and further extended with curved tenotomy scissors.  using a curved mosquito clamp, we gently dissected into the inguinal canal until we got the hernia sac and dissected it out of the canal.  the cord structures were then dissected off the sac and then the sac itself was divided in the midline, twisted upon itself and suture ligated up at the peritoneal reflection with 3-0 vicryl suture.  this was done twice.  the distal end where a large hydrocele noted, was gently milked into the lower aspect of the incision.  the hydrocele sac was then opened and drained and then the testis was delivered into the field.  the sac was then opened completely around the testis.  the appendix testis was cauterized.  we wrapped the sac around the back of the testis and tacked into place using the lord maneuver using 4-0 vicryl as a figure-of-eight suture.  once this was done, the testis was then placed back into the scrotum in the proper orientation.  ilioinguinal nerve block and wound instillation was then done with 10 ml of 0.25% marcaine.  a similar procedure was done on the left side, also finding a small hernia, which was divided and ligated with the 3-0 vicryl as on the right side and distally the hydrocele sac was also wrapped around the back of the testis in a lord maneuver after opening the sac completely.  again both testes were placed into the scrotum after the hydroceles were treated and then the external oblique fascia was closed on both sides with a running suture of 3-0 vicryl ensuring that the ilioinguinal nerve and the cord structures not involved in the closure.  scarpa fascia was closed with 4-0 chromic suture on each side and the skin was closed with 4-0 rapide subcuticular closure.  dermabond tissue adhesive was placed on both incisions.  iv toradol was given at the end of the procedure and both testes were well descended within the scrotum at the end of the procedure.  the patient tolerated the procedure and was in stable condition upon transfer to the recovery room.",37
"reason for consult:,  depression.,hpi:,  the patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before thanksgiving in 2006.  the patient was diagnosed and treated for a t9 compression fraction with vertebroplasty.  soon after discharge, the patient was readmitted with severe mid low back pain and found to have a t8 compression fracture.  this was also treated with vertebroplasty.  the patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  her pain is in her upper back around her shoulder blades.  the patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  mri on january 29, 2007, was positive for possible meningioma to the left of anterior box.,the patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  does not see any future for herself.  reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  admits to decreased appetite, feeling depressed, and always wanting to be alone.  claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at terrace.  denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  denies auditory and visual hallucinations.  no paranoid, delusions, or other abnormalities of thought content.  denies panic attacks, flashbacks, and other feelings of anxiety.  does admit to feeling restless at times.  is concerned with her physical appearance while in the hospital, i.e., her hair looking ""awful."",past medical history:,  hypertension, cataracts, hysterectomy, mi, osteoporosis, right total knee replacement in april 2004, hip fracture, and newly diagnosed diabetes.  no history of thyroid problems, seizures, strokes, or head injuries.,current medications:,  norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, lipitor 20 mg p.o. daily, klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, lexapro 10 mg p.o. daily, tricor 145 mg p.o. each bedtime, lasix 20 mg p.o. daily, ismo 20 mg p.o. daily, lidocaine patch, zestril, prinivil 40 mg p.o. daily, lopressor 75 mg p.o. b.i.d., starlix 120 mg p.o. t.i.d., pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 meq p.o. t.i.d., norco one tablet p.o. q.4h. p.r.n., zofran 4 mg iv q.6h.,home medications:,  unknown.,allergies:,  codeine (hallucinations).,family medical history:,  unremarkable.,past psychiatric history:,  unremarkable.  never taken any psychiatric medications or have ever had a family member with psychiatric illness.,social/developmental history:,  unremarkable childhood.  married for 40 plus years, widowed in 1981.  worked as administrative assistant in utmb hospitals vp's office.  two children.  before admission, lived in the terrace independent living center.  was happy and very active while living there.  had friends in the terrace and would not mind going back there after discharge.  occasional glass of wine at dinner.  denies ever using illicit drugs and tobacco.,mental status exam:,  the patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  slight decrease in motor activity.  normal eye contact.  speech, low volume and rate.  good articulation and inflexion.  normal concentration.  mood, labile, tearful at times, depressed, then euthymic.  affect, mood congruent, full range.  thought process, logical and goal directed.  thought content, no delusions, suicidal or homicidal ideations.  perception, no auditory or visual hallucinations.  sensorium, alert, and oriented x3.  memory, fair.  information and intelligence, average.  judgment and insight, fair.,mini mental status exam,:  a 28/30.  could not remember two out of the three recalled words.,assessment:,  the patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  the patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,axis i:  major depression disorder.,axis ii:  deferred.,axis iii:  osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, mi, and right total knee replacement.,axis iv:  lives independently at terrace, difficulty walking, hospitalization.,axis v:  45.,plan:,  continue lexapro 10 mg daily and pamelor 25 mg each bedtime monitor for adverse effects of tca and worsening of depressive symptoms.  discussed about possible inpatient psychiatric care.,thank you for the consultation.",30
"exam: , ultrasound examination of the scrotum.,reason for exam: , scrotal pain.,findings:  ,duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed.  the left testicle measures 5.1 x 2.8 x 3.0 cm.  there is no evidence of intratesticular masses.  there is normal doppler blood flow.  the left epididymis has an unremarkable appearance.  there is a trace hydrocele.,the right testicle measures 5.3 x 2.4 x 3.2 cm.  the epididymis has normal appearance.  there is a trace hydrocele.  no intratesticular masses or torsion is identified.  there is no significant scrotal wall thickening.,impression:  ,trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.",31
"nerve conduction testing and emg evaluation,1.  right median sensory response 3.0, amplitude 2.5, distance 100.,2.  right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  left median sensory response 3.0, amplitude 1.2, distance 100.,4.  left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,needle emg testing,1.  ,right biceps:,  fibrillations 0, fasciculations occasional, positive waves 0.  motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,right triceps:,  fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,extensor digitorum:,  fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,first dorsal interosseous: , fibrillations 2+, fasciculations 1+, positive waves 2+.  motor units, decreased number of motor units firing.,5.  ,right abductor pollicis brevis:,  fibrillations 1+, fasciculations 1+, positive waves 0.  motor units, decreased number of motor units firing.,6. , flexor carpi ulnaris:,  fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  motor units, decreased number of motor units firing.,7.  ,left first dorsal interosseous:,  fibrillations 1+, fasciculations 1+, positive waves occasional.  motor units, decreased number of motor units firing.,8.  ,left extensor digitorum:,  fibrillations 1+, fasciculations 1+.  motor units, decreased number of motor units firing.,9.  ,right vastus medialis:,  fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  motor units, decreased number of motor units firing.,10.  ,anterior tibialis: , fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  motor units, increased proportion of polyphasic units and decreased number of motor units firing.  there is again increased needle insertional activity.,11.  ,right gastrocnemius:,  fibrillations 1+, fasciculations 1+, positive waves 1+.  motor units, marked decreased number of motor units firing.,12.  ,left gastrocnemius:,  fibrillations 1+, fasciculations 1+, positive waves 2+.  motor units, marked decreased number of motor units firing.,13.  ,left vastus medialis: , fibrillations occasional, fasciculations occasional, positive waves 1+.  motor units, decreased number of motor units firing.,impression: ",28
"diagnosis:,  stasis ulcers of the lower extremities,operation:,  split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,indications:,  this 84-year old female presented recently with large ulcers of the lower extremities.  these were representing on the order of 50% or more of the circumference of her lower leg.  they were in a distribution to be consistent with stasis ulcers.  they were granulating nicely and she was scheduled for surgery.,findings:,  large ulcers of lower extremities with size as described above.  these are irregular in shape and posterior and laterally on the lower legs.  there was no evidence of infection.  the ultimate skin grafting was quite satisfactory.,procedure: , having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  the legs were examined and the wounds were pulsavaced bilaterally with 3 liters of saline with bacitracin.  the wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  this was meshed 1:1.5 and then stapled into position on the wounds.  the wounds were then dressed with a fine mesh gauze that was stapled into position as well as kerlix soaked in sulfamylon solution.,she was then dressed in additional kerlix, followed by webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  the donor site was dressed with op-site.  the patient tolerated the procedure well and returned to the recovery room in satisfactory condition.",36
"subjective:,  the patient is brought in by an assistant with some of his food diary sheets.  they wonder if the patient needs to lose anymore weight.,objective:,  the patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  he has lost a total of 34-1/2 pounds.  i praised this.  i went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free kool-aid, sugar-free pudding, and diet pop.  i encouraged him to continue all of that, as well as his regular physical activity.,assessment:,  the patient is losing weight at an acceptable rate.  he needs to continue keeping a food diary and his regular physical activity.,plan:,  the patient plans to see dr. xyz at the end of may 2005.  i recommended that they ask dr. xyz what weight he would like for the patient to be at.  follow up will be with me june 13, 2005.",4
"nerve conduction testing and emg evaluation,1.  right median sensory response 3.0, amplitude 2.5, distance 100.,2.  right ulnar sensory response 2.1, amplitude 1, distance 90.,3.  left median sensory response 3.0, amplitude 1.2, distance 100.,4.  left median motor response distal 4.2, proximal 9, amplitude 2.2, distance 290, velocity 60.4 m/sec.,5.  right median motor response distal 4.3, proximal 9.7, amplitude 2, and velocity 53.7 m/sec.,6.  right ulnar motor response distal 2.5, proximal 7.5, amplitude 2, distance 300, velocity 60 m/sec.,needle emg testing,1.  ,right biceps:,  fibrillations 0, fasciculations occasional, positive waves 0.  motor units, increased needle insertional activity and mild decreased number of motor units firing.,2.  ,right triceps:,  fibrillations 1+, fasciculations occasional to 1+, positive waves 1+.  motor units, increased needle insertional activity and decreased number of motor units firing.,3.  ,extensor digitorum:,  fibrillations 0, fasciculations rare, positive waves 0, motor units probably normal.,4.  ,first dorsal interosseous: , fibrillations 2+, fasciculations 1+, positive waves 2+.  motor units, decreased number of motor units firing.,5.  ,right abductor pollicis brevis:,  fibrillations 1+, fasciculations 1+, positive waves 0.  motor units, decreased number of motor units firing.,6. , flexor carpi ulnaris:,  fibrillations 1+, occasionally entrained, fasciculations rare, positive waves 1+.  motor units, decreased number of motor units firing.,7.  ,left first dorsal interosseous:,  fibrillations 1+, fasciculations 1+, positive waves occasional.  motor units, decreased number of motor units firing.,8.  ,left extensor digitorum:,  fibrillations 1+, fasciculations 1+.  motor units, decreased number of motor units firing.,9.  ,right vastus medialis:,  fibrillations 1+ to 2+, fasciculations 1+, positive waves 1+.  motor units, decreased number of motor units firing.,10.  ,anterior tibialis: , fibrillations 2+, occasionally entrained, fasciculations 1+, positive waves 1+.  motor units, increased proportion of polyphasic units and decreased number of motor units firing.  there is again increased needle insertional activity.,11.  ,right gastrocnemius:,  fibrillations 1+, fasciculations 1+, positive waves 1+.  motor units, marked decreased number of motor units firing.,12.  ,left gastrocnemius:,  fibrillations 1+, fasciculations 1+, positive waves 2+.  motor units, marked decreased number of motor units firing.,13.  ,left vastus medialis: , fibrillations occasional, fasciculations occasional, positive waves 1+.  motor units, decreased number of motor units firing.,impression: ",20
"procedure performed: , endotracheal intubation.,indication for procedure:  ,the patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  pco2 was 29 and po2 was 66 on the 15 liters.,narrative of procedure: , the patient was given a total of 5 mg of versed, 20 mg of etomidate, and 10 mg of vecuronium.  he was intubated in a single attempt.  cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap a lavage with 100 ml of normal sterile saline for cytology, afb, and fungal smear and culture.  a separate trap b was then lavaged for bacterial c&s and gram stain and was sent for those purposes.  the patient tolerated the procedure well.",36
"exam:,mri of the left knee without contrast,clinical:,left knee pain. twisting injury.,findings:,the images reveal a sizable joint effusion. the joint effusion appears to be complex with mixed signal intensity material within. the patella is slightly laterally tilted towards the left. the mid portion of the patella cartilage shows some increased signal and focal injury to the patellar cartilage is suspected. mildly increased bone signal overlying the inferolateral portion of the patella is identified. no significant degenerative changes about the patella can be seen. the quadriceps tendon as well as the infrapatellar ligament both look intact. there is some prepatellar soft tissue edema.,the bone signal shows a couple of small areas of cystic change in the proximal aspect of the tibia. no significant areas of bone edema are appreciated.,there is soft tissue edema along the lateral aspect of the knee. there is a partial tear of the lateral collateral ligament complex. the medial collateral ligament complex looks intact. a small amount of edema is identified immediately adjacent to the medial collateral ligament complex.,the posterior cruciate ligament looks intact. the anterior cruciate ligament is thickened with significant increased signal. i suspect at least a high grade partial tear.,the posterior horn of the medial meniscus shows some myxoid degenerative changes. the posterior horn and anterior horn of the lateral meniscus likewise shows myxoid degenerative type changes. i don’t see a definite tear extending to the articular surface.,impression:,sizeable joint effusion which is complex and may contain blood products.,myxoid degenerative type changes medial and lateral meniscus with no definite evidence of a tear.,soft tissue swelling and partial tear of the lateral collateral ligament complex.,at least high grade partial tear of the anterior cruciate ligament with significant thickening and increased signal of this structure.,the posterior cruciate ligament is intact.,injury to the patellar cartilage as above.",31
"subjective:,  the patient is brought in by an assistant with some of his food diary sheets.  they wonder if the patient needs to lose anymore weight.,objective:,  the patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  he has lost a total of 34-1/2 pounds.  i praised this.  i went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free kool-aid, sugar-free pudding, and diet pop.  i encouraged him to continue all of that, as well as his regular physical activity.,assessment:,  the patient is losing weight at an acceptable rate.  he needs to continue keeping a food diary and his regular physical activity.,plan:,  the patient plans to see dr. xyz at the end of may 2005.  i recommended that they ask dr. xyz what weight he would like for the patient to be at.  follow up will be with me june 13, 2005.",8
"exam: , five views of the right knee.,history: , pain.  the patient is status-post surgery, he could not straighten his leg, pain in the back of the knee.,technique:,  five views of the right knee were evaluated.  there are no priors for comparison.,findings: , five views of the right knee were evaluated and they reveal there is no evidence of any displaced fractures, dislocations, or subluxations.  there are multiple areas of growth arrest lines seen in the distal aspect of the femur and proximal aspect of the tibia.  there is also appearance of a high-riding patella suggestive of patella alta.,impression:,1.  no evidence of any displaced fractures, dislocations, or subluxations.,2.  growth arrest lines seen in the distal femur and proximal tibia.,3.  questionable appearance of a slightly high-riding patella, possibly suggesting patella alta.",31
"preoperative diagnosis:,  cranial defect greater than 10 cm in diameter in the frontal region.,postoperative diagnosis: , cranial defect greater than 10 cm in diameter in the frontal region.,procedure: , bifrontal cranioplasty.,anesthesia:,  general endotracheal anesthesia.,estimated blood loss: , nil.,indications for procedure: , the patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  the most recent one which i performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  he has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  after discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  he had previously undergone a ct scan.  premanufactured cranioplasty made for him that was sterile and ready to implant.,description of procedure: , after induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  we identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  he was given intravenous antibiotics with ceftriaxone, vancomycin, and flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  the scalp was prepped and draped in the usual sterile fashion.  a previous incision was reopened and the scalp flap was reflected forward.  we dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  we freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  we did explore laterally and saw a little bit of the mesh on the lateral orbit.  once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  we had achieved good hemostasis.  the wound was closed in multiple layers in usual fashion over a blake drain.  at the end of the procedure, all sponge and needle counts were correct.  a sterile dressing was applied to the incision.  the patient was transported to the recovery room in good condition after having tolerated the procedure well.  i was personally present and scrubbed and performed/supervised all key portions.",36
"reason for the visit:,  very high pt/inr.,history: , the patient is an 81-year-old lady whom i met last month when she came in with pneumonia and chf.  she was noticed to be in atrial fibrillation, which is a chronic problem for her.  she did not want to have coumadin started because she said that she has had it before and the inr has had been very difficult to regulate to the point that it was dangerous, but i convinced her to restart the coumadin again.  i gave her the coumadin as an outpatient and then the inr was found to be 12.  so, i told her to come to the emergency room to get vitamin k to reverse the anticoagulation.,past medical history:,1.  congestive heart failure.,2.  renal insufficiency.,3.  coronary artery disease.,4.  atrial fibrillation.,5.  copd.,6.  recent pneumonia.,7.  bladder cancer.,8.  history of ruptured colon.,9.  myocardial infarction.,10.  hernia repair.,11.  colon resection.,12.  carpal tunnel repair.,13.  knee surgery.,medications:,1.  coumadin.,2.  simvastatin.,3.  nitrofurantoin.,4.  celebrex.,5.  digoxin.,6.  levothyroxine.,7.  vicodin.,8.  triamterene and hydrochlorothiazide.,9.  carvedilol.,social history:  ,she does not smoke and she does not drink.,physical examination:,general:  lady in no distress.,vital signs:  blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,heent:  head is normal.,neck:  supple.,lungs:  clear to auscultation and percussion.,heart:  no s3, no s4, and no murmurs.,abdomen:  soft.,extremities:  lower extremities, no edema.,assessment:,1.  atrial fibrillation.,2.  coagulopathy, induced by coumadin.,plan: , her inr at the office was 12.  i will repeat it, and if it is still elevated, i will give vitamin k 10 mg in 100 ml of d5w and then send her home and repeat the pt/inr next week.  i believe at this time that it is too risky to use coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  she is prone to a fall and this would be a big problem.  we will use one aspirin a day instead of the anticoagulation.  she is aware of the risk of stroke, but she is very scared of the anticoagulation with coumadin and does not want to use the coumadin at this time and i understand.  we will see her as an outpatient.",2
"chief complaint:,  right-sided facial droop and right-sided weakness.,history of present illness: , the patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation.  while in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop.  the ct scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.,allergies: , she is allergic to penicillin.,social history: , she is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.,family history: , noncontributory.,past medical history:,1.  cerebrovascular accident with expressive aphasia and lower extremity weakness.,2.  abnormality of gait and wheelchair bound secondary to #1.,3.  hypertension.,4.  chronic obstructive pulmonary disease, on nasal oxygen.,5.  anxiety disorder.,6.  dementia.,past surgical history: , status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.,review of systems: , because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.,physical examination:,general:  she is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.,vital signs:  temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.,heent:  pupils are equal, round, and reactive to light.  external ocular muscles are intact.  conjunctivae anicteric.  there is a slight right-sided facial droop.  oropharynx is clear with the missing teeth on the upper and the lower part.  tympanic membranes are clear.,neck:  supple.  there is no carotid bruit.  no cervical adenopathy.,cardiac:  regular rate and rhythm with 2/6 systolic murmur, more at the apex.,lungs:  clear to auscultation.,abdomen:  soft and no tenderness.  bowel sound is present.,extremities:  there is no pedal edema.  both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.,neurologic:  there is right-sided slight facial droop.  she moves both upper extremities equally.  she has withdrawal of both lower extremities by touching her sole of the feet.,skin:  there is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.,laboratory data: , the ct scan of the head shows brain atrophy with no acute events.  sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, bun of 22, creatinine 0.5, and glucose of 92.  total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000.  the urinalysis was more than 100 white blood cells and 10-25 red blood cells.  recent culture showed more than 100,000 colonies of e. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.,assessment:,1.  recent cerebrovascular accident with right-sided weakness.,2.  hypertension.,3.  dementia.,4.  anxiety.,5.  urinary tract infection.,6.  abnormality of gait secondary to lower extremity weakness.,plan: , we will keep the patient npo until a swallowing evaluation was done.  we will start her on iv vasotec every 4 hours p.r.n. systolic blood pressure more than 170.  neuro check every 4 hours for 24 hours.  we will start her on amikacin iv per pharmacy.  we will start her on lovenox subcutaneously 40 mg every day and we will continue with the ecotrin as swallowing evaluation was done.  resume home medications, which basically include aricept 10 mg p.o. daily, diovan 160 mg p.o. daily, multivitamin, calcium with vitamin d, ecotrin, and tylenol p.r.n.  i will continue with the iv fluids at 75 ml an hour with a d5 normal saline at the range of 75 ml an hour and adding potassium 10 meq per 1000 ml and i would follow the patient on daily basis.",14
"preoperative diagnosis:,  acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,postoperative diagnosis:,  acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,procedures:,1.  osteosynthesis of acetabular fracture on the left, complex variety.,2.  total hip replacement.,anesthesia: , general.,complications: , none.,description of procedure: , the patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  kocher langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  the femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  the piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  the major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  it should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  once this was accomplished, the procedure was turned over to dr. x and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  this will be dictated in separate note.  the patient tolerated the procedure well.  the sciatic nerve was well protected and directly visualized to the level of the notch.",36
"preoperative diagnoses: , left cubital tunnel syndrome and ulnar nerve entrapment.,postoperative diagnoses: , left cubital tunnel syndrome and ulnar nerve entrapment.,procedure performed: , decompression of the ulnar nerve, left elbow.,anesthesia: , general.,findings of the operation:,  the ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  there was presence of hourglass constriction of the ulnar nerve.,procedure: , the patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  a sterile tourniquet was positioned and tourniquet was inflated at 250 mmhg.  perioperative antibiotics were infused.  time-out procedure was called.  the medial epicondyle and the olecranon tip were well palpated.  the incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  the ulnar nerve was identified proximally.  it was mobilized with a blunt and a sharp dissection proximally to the arcade of struthers, which was released sharply.  the roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  the ulnar nerve was well-isolated before it entered the cubital tunnel.  the arch of the fcu was well defined.  the fascia was elevated from the nerve and both the fcu fascia and the osborne fascia were divided protecting the nerve under direct visualization.  distally, the dissection was carried between the 2 heads of the fcu.  decompression of the nerve was performed between the heads of the fcu.  the muscular branches were well protected.  similarly, the cutaneous branches in the arm and forearm were well protected.  the venous plexus proximally and distally were well protected.  the nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  there was no evidence of any subluxation.  satisfactory decompression was performed.  tourniquet was released.  hemostasis was achieved.  subcutaneous layer was closed with 2-0 vicryl and skin was approximated with staples.  a well-padded dressing was applied.  the patient was then extubated and transferred to the recovery room in stable condition.  there were no intraoperative complications noted.  the patient tolerated the procedure very well.",25
"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.,",36
"indications for procedure:, a 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. the chest pain occurred early tuesday morning. she was treated with plavix, lovenox, etc., and transferred for coronary angiography and possible pci. the plan was discussed with the patient and all questions answered.,procedure note:, following sterile prep and drape, the right groin and instillation of 1% xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. a 6-french sheath inserted. selective left and right coronary injections performed using judkins coronary catheters with a 6-french pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. the left pullback pressure. the catheters withdrawn. sheath injection. hemostasis obtained with a 6-french angio-seal device. she tolerated the procedure well.,left ventricular end-diastolic pressure equals 25 mmhg post a wave. no aortic valve or systolic gradient on pullback.,angiographic findings:,i. left coronary artery: the left main coronary artery is,normal. the left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. normal diagonal branches. normal septal perforator branches. the left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,ii. right coronary artery: the proximal right coronary artery has a focal calcification. there is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. the right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. timi 3 flow is present.,iii. left ventriculogram: the left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,discussion:, recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post a wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,plan:, medical treatment is contemplated, including ace inhibitor, a beta blocker, aspirin, plavix, nitrates. an echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.",36
"history of present illness: , the patient is a 55-year-old hispanic male who was seen initially in the office february 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  the patient at that time stated that he had established diagnosis of liver cirrhosis.  since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, dr. x in las cruces and his primary care physician in silver city, and unfortunately we did not get any information from anybody.  also the patient had admission in gila medical center with epigastric pain, diarrhea, and confusion.  he spent 3 days in the hospital.  he was followed by dr. x and unfortunately we also do not have the information of what was wrong with the patient.  from the patient's report he was diagnosed with some kind of viral infection.  at the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,physical examination,vital signs:  weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,heent:  perrla.  eom intact.  oropharynx is clear of lesions.,neck:  supple.  no lymphadenopathy.  no thyromegaly.,lungs:  clear to auscultation and percussion bilateral.,cardiovascular:  regular rate and rhythm.  no murmurs, rubs, or gallops.,abdomen:  not tender, not distended.  splenomegaly about 4 cm under the costal margin.  no hepatomegaly.  bowel sounds present.,musculoskeletal:  no cyanosis, no clubbing, no pitting edema.,neurologic:  nonfocal.  no asterixis.  no costovertebral tenderness.,psyche:  the patient is oriented x4, alert and cooperative.,laboratory data: , we were able to collect lab results from medical center; we got only cmp from the hospital which showed glucose level 79, bun 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, co2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  his ast 56, alt 37, alkaline phosphatase 165, and his ammonia level was 53.  we do not have any other results back.  no hepatitis panels.  no alpha-fetoprotein level.  the patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,assessment and plan:,  the patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  epigastric pain.  the patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  in the office twice the patient did not have any abdominal pain on physical exam.  his pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  he probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  end-stage liver disease.  of course, we need to find out the cause of the liver cirrhosis.  we do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  we do not have any information of any type of investigation in the past.  again, patient was seen by gastroenterologist already in las cruces, dr. x.  the patient was advised to contact dr. x by himself to convince him to send available information because we already send release information form signed by the patient without any result.  it will be not reasonable to repeat unnecessary tests in that point in time.,we are waiting for the hepatitis panel and alpha-fetoprotein level.  we will also need to get information about ultrasound which was done in gila medical center, but obviously no tumor was found on this exam of the liver.  we have to figure out hepatitis status for another reason if he needs vaccination against hepatitis a and b.  until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis c.  the patient denied any excessive alcohol intake, but i could not preclude alcohol-related liver cirrhosis also.  we will need to look for nuclear antibody if it is not done before.  psc is extremely unlikely but possible.  wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  on his end-stage liver disease we already know that he had low platelet count splenomegaly.  we know that his bilirubin is elevated and albumin is very low.  i suspect that at the time of admission to the hospital the patient presented with encephalopathy.  we do not know if inr was checked to look for coagulopathy.  the patient had an egd in 2005 as well as colonoscopy in silver city.  we have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,at this point in time, i recommended the patient to continue to take lactulose 50 ml 3 times daily.  the patient tolerated it well; no diarrhea at this point in time.  i also recommended for him to contact his primary care physician for increased dose of opiates for him.  as a primary prophylaxis of gi bleeding in patient with end-stage liver disease we will try to use inderal.  the patient got a prescription for 10 mg pills.  he will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  the patient was educated how to use inderal and he was explained why we decided to use this medication.  the patient will hold this medication if he is orthostatic or bradycardic.,again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests i mentioned above.,we also discussed nutrition issues.  the patient was provided information that his protein intake is supposed to be about 25 g per day.  he was advised not to over-eat protein and advised not to starve.  he also was advised to stay away from alcohol.  his next visit is in 2 weeks with all results available.",13
"history of present illness:  ,the patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain.  he states that a little less than a year ago he developed pain in his right arm.  it is intermittent, but has persisted since that time.  he describes that he experiences a dull pain in his upper outer arm.  it occurs on a daily basis.  he also experiences an achy sensation in his right hand radiating to the fingers.  there is no numbness or paresthesias in the hand or arm.,he has had a 30-year history of neck pain.  he sought medical attention for this problem in 2006, when he developed ear pain.  this eventually led to him undergoing an mri of the cervical spine, which showed some degenerative changes.  he was then referred to dr. x for treatment of neck pain.  he has been receiving epidural injections under the care of dr. x since 2007.  when i asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain.  he also has taken several medrol dose packs, which has caused his blood sugars to increase.  he is taking multiple other pain medications.  the pain does not interfere significantly with his quality of life, although he has a constant nagging pain.,past medical history: , he has had diabetes since 2003.  he also has asthma, hypertension, and hypercholesterolemia.,current medications: , he takes actoplus, albuterol, androgel, astelin, diovan, dolgic plus, aspirin 81 mg, fish oil, lipitor, lorazepam, multivitamins, nasacort, pulmicort, ranitidine, singulair, viagra, zetia, zyrtec, and uroxatral.  he also uses lidoderm patches and multiple eye drops and creams.,allergies:,  he states that dyazide, zithromax, and amoxicillin cause him to feel warm and itchy.,family history:,  his father died from breast cancer.  he also had diabetes.  he has a strong family history of diabetes.  his mother is 89.  he has a sister with diabetes.  he is unaware of any family members with neurological disorders.,social history:,  he lives alone.  he works full time in human resources for the state of maryland.  he previously was an alcoholic, but quit in 1984.  he also quit smoking cigarettes in 1984, after 16 years of smoking.  he has a history of illicit drug use, but denies iv drug use.  he denies any hiv risk factors and states that his last hiv test was over two years ago.,review of systems: , he has intermittent chest discomfort.  he has chronic tinnitus.  he has urinary dribbling.  otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  this is documented in the handwritten notes from today's visit.,physical examination:,vital signs:  hr 72. rr 16.,general appearance:  patient is well appearing, in no acute distress.,cardiovascular:  there is a regular rhythm without murmurs, gallops, or rubs.  there are no carotid bruits.,chest:  the lungs are clear to auscultation bilaterally.,skin:  there are no rashes or lesions.,neurological examination:,mental status:  speech is fluent without dysarthria or aphasia.  the patient is alert and oriented to name, place, and date.  attention, concentration, registration, recall, and fund of knowledge are all intact.,cranial nerves:  pupils are equal, round, and reactive to light and accommodation.  optic discs are normal.  visual fields are full.  extraocular movements are intact without nystagmus.  facial sensation is normal.  there is no facial, jaw, palate, or tongue weakness.  hearing is grossly intact.  shoulder shrug is full.,motor:  there is normal muscle bulk and tone.  there is no atrophy or fasciculations.  there is no action or percussion myotonia or paramyotonia.  manual muscle testing reveals mrc grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.,sensory:  sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense.  romberg is absent.,coordination:  there is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.,deep tendon reflexes:  deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles.  plantar reflexes are flexor.  there are no finger flexors, hoffman's sign, or jaw jerk.,gait and stance:  casual gait is normal.  heel, toe, and tandem walking are all normal.,radiologic data:,  mri of the cervical spine, 05/19/08:  i personally reviewed this film, which showed narrowing of the foramen on the right at c4-c5 and other degenerative changes without central stenosis.,impression:  ,the patient is a 58-year-old gentleman with one-year history of right arm pain.  he also has a longstanding history of neck pain.  his neurological examination is normal.  he has an mri that shows some degenerative changes.  i do believe that his symptoms are probably referable to his neck.  however, i do not think that they are severe enough for him to undergo surgery at this point in time.  perhaps another course of physical therapy may be helpful for him.  i probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal.  we could still try to treat him with neuropathic pain medications.,recommendations:,1.  i scheduled him to return for an emg and nerve conduction studies to determine whether there is any evidence of nerve damage, although i think the likelihood is low.,2.  i gave him a prescription for neurontin.  i discussed the side effects of the medication with him.,3.  we can discuss his case tomorrow at spine conference to see if there are any further recommendations.",4
"preoperative diagnosis:,  brain tumor left temporal lobe.,postoperative diagnosis:,  brain tumor left temporal lobe - glioblastoma multiforme.,operative procedure:,1.  left temporal craniotomy.,2.  removal of brain tumor.,operating microscope: , stealth.,procedure: , the patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  the entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  next, we made an inverted-u fashion base over the asterion over temporoparietal area of the skull.  a free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  the bone flap was placed aside and soaked in the bacitracin solution.,the dura was then opened in an inverted-u fashion.  using the stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  we head through the vein of labbe, and we made great care to preserve this.  we saw where the tumor almost made to the surface.  here we made a small corticectomy using the stealth for guidance.  we left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  this was submitted to pathology.  we biopsied this very abnormal tissue and submitted it to pathology.  they gave us a frozen section diagnosis of glioblastoma multiforme.  with the operating microscope and greenwood bipolar forceps, we then systematically debulked this tumor.  it was very vascular and we really continued to remove this tumor until all visible tumors was removed.  we appeared to get two gliotic planes circumferentially.  we could see it through the ventricle.  after removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 nurolon sutures with the piece of duragen placed over this in order to increase our chances for a good watertight seal.  the bone flap was then replaced and sutured with the lorenz titanium plate system.  the muscle fascia galea was closed with interrupted 2-0 vicryl sutures.  skin staples were used for skin closure.  the blood loss of the operation was about 200 cc.  there were no complications of the surgery per se.  the needle count, sponge count, and the cottonoid count were correct.,comment:  ,operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could i think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.",36
"title of operation: , intramedullary nail fixation of the left tibia fracture with a stryker t2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (cpt code is 27759) (the icd-9 code again is 823.2 for a tibial shaft fracture).,indication for surgery:  ,the patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  the patient was admitted and splinted and had compartment checks.  the risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  the patient understood these risks and wished to proceed.,preop diagnosis: , left tibial shaft fracture status post gunshot wound (cpt code 27759).,postop diagnosis: , left tibial shaft fracture status post gunshot wound (cpt code 27759).,anesthesia: , general endotracheal.,intravenous fluid:,  900.,estimated blood loss:  ,100.,complications:,  none.,disposition: , stable to pacu.,procedure detail:  ,the patient was met in the preoperative holding area and operative site was marked.  the patient was brought to the operating room and given preoperative antibiotics.  left leg was then prepped and draped in the usual sterile fashion.  a midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  the starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  this was advanced and confirmed on the ap and lateral fluoroscopic images.  the opening reamer was then used and the ball-tip guidewire was passed.  the reduction was obtained over a large radiolucent triangle.  after passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  at this point, a 10 x 390 mm was passed without difficulty.  the guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  the final images were taken with fluoroscopy and a 15-mm end-cap was placed.  the wounds were then irrigated and closed with 2-0 vicryl followed by staples to the distal screws and 0 vicryl followed 2-0 vicryl and staples to the proximal incision.  the patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,the plan will be nonweightbearing left lower extremity.  he will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.",36
"preoperative diagnosis:,  varicose veins.,postoperative diagnosis: , varicose veins.,procedure performed:,1.  ligation and stripping of left greater saphenous vein to the level of the knee.,2.  stripping of multiple left lower extremity varicose veins.,anesthesia:,  general endotracheal.,estimated blood loss: , approximately 150 ml.,specimens: , multiple veins.,complications:,  none.,brief history:,  this is a 30-year-old caucasian male who presented for elective evaluation from dr. x's office for evaluation of intractable pain from the left lower extremity.  the patient has had painful varicose veins for number of years.  he has failed conservative measures and has felt more aggressive treatment to alleviate his pain secondary to his varicose veins.  it was recommended that the patient undergo a saphenous vein ligation and stripping.  he was explained the risks, benefits, and complications of the procedure including intractable pain.  he gave informed consent to proceed.,operative findings:,  the left greater saphenous vein femoral junction was identified and multiple tributaries were ligated surrounding this region.,the vein was stripped from the saphenofemoral junction to the level of the knee.  multiple tributaries of the greater saphenous vein and varicose veins from the left lower extremity were ligated and stripped accordingly.  additionally, there were noted to be multiple regions within these veins that were friable and edematous consistent with acute and chronic inflammatory changes making stripping of these varicose veins extremely difficult.,operative procedure:  ,the patient was marked preoperatively in the preanesthesia care unit.  the patient was brought to the operating suite, placed in the supine position.  the patient underwent general endotracheal intubation.  after adequate anesthesia was obtained, the left lower extremity was prepped and draped circumferentially from the foot all the way to the distal section of the left lower quadrant and just right of midline.  a diagonal incision was created in the direction of the inguinal crease on the left.  a self-retaining retractor was placed and the incision was carried down through the subcutaneous tissues until the greater saphenous vein was identified.  the vein was isolated with a right angle.  the vein was followed proximally until a multiple tributary branches were identified.  these were ligated with #3-0 silk suture.  the dissection was then carried to the femorosaphenous vein junction.  this was identified and #0 silk suture was placed proximally and distally and ligated in between.  the proximal suture was tied down.  distal suture was retracted and a vein stripping device was placed within the greater saphenous vein.  an incision was created at the level of the knee.  the distal segment of the greater saphenous vein was identified and the left foot was encircled with #0 silk suture and tied proximally and then ligated.  the distal end of the vein stripping device was then passed through at its most proximal location.  the device was attached to the vein stripping section and the greater saphenous vein was then stripped free from its canal within the left lower extremity.  next, attention was made towards the multiple tributaries of the varicose vein within the left lower leg.  multiple incisions were created with a #15 blade scalpel.  the incisions were carried down with electrocautery.  next, utilizing sharp dissection with a hemostat, the tissue was spread until the vein was identified.  the vein was then followed to t3 and in all these locations intersecting segments of varicose veins were identified and removed.  additionally, some segments were removed.  the stripping approach would be vein stripping device.  multiple branches of the saphenous vein were then ligated and/or removed.  occasionally, dissection was unable to be performed as the vein was too friable and would tear from the hemostat.  bleeding was controlled with direct pressure.  all incisions were then closed with interrupted #3-0 vicryl sutures and/or #4-0 vicryl sutures.,the femoral incision was closed with interrupted multiple #3-0 vicryl sutures and closed with a running #4-0 subcuticular suture.  the leg was then cleaned, dried, and then steri-strips were placed over the incisions.  the leg was then wrapped with a sterile kerlix.  once the kerlix was achieved, an ace wrap was placed over the left lower extremity for compression.  the patient tolerated the procedure well and was transferred to postanesthesia care unit extubated in stable condition.  he will undergo evaluation postoperatively and will be seen shortly in the postanesthesia care unit.",36
"preliminary diagnoses:,1.  contusion of the frontal lobe of the brain.,2.  closed head injury and history of fall.,3.  headache, probably secondary to contusion.,final diagnoses:,1.  contusion of the orbital surface of the frontal lobes bilaterally.,2.  closed head injury.,3.  history of fall.,course in the hospital: , this is a 29-year-old male, who fell at home.  he was seen in the emergency room due to headache.  ct of the brain revealed contusion of the frontal lobe near the falx.  the patient did not have any focal signs.  he was admitted to abcd.  neurology consultation was obtained.  neuro checks were done.  the patient continued to remain stable, although he had some frontal headache.  he underwent an mri to rule out extension of the contusion or the possibility of a bleed and the mri of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  the patient remained clinically stable and his headache resolved.  he was discharged home on 11/6/2008.,plan: , discharge the patient to home.,activity:  ,as tolerated.,the patient has been advised to call if the headache is recurrent and tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  the patient has been advised to follow up with me as well as the neurologist in about 1 week.",20
"indication:,  prostate cancer.,technique:,  3.5 hours following the intravenous administration of 26.5 mci of technetium 99m mdp, the skeleton was imaged in the anterior and posterior projections.,findings:,  there is a focus of abnormal increased tracer activity overlying the right parietal region of the skull.  the uptake in the remainder of the skeleton is within normal limits.  the kidneys image normally.  there is increased activity in the urinary bladder suggesting possible urinary retention.,conclusion:,1.  focus of abnormal increased tracer activity overlying the right parietal region of the skull.  ct scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2.  there is probably some degree of urinary retention.,",31
"preoperative diagnoses:,1.  chronic renal failure.,2.  thrombosed left forearm arteriovenous gore-tex bridge fistula.,postoperative diagnosis:,1.  chronic renal failure.,2.  thrombosed left forearm arteriovenous gore-tex bridge fistula.,procedure performed:,1.  fogarty thrombectomy, left forearm arteriovenous gore-tex bridge fistula.,2.  revision of distal anastomosis with 7 mm interposition gore-tex graft.,anesthesia:,  general with controlled ventillation.,gross findings: , the patient is a 58-year-old black male with chronic renal failure.  he undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level.  there is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,operative procedure: , the patient was taken to the or suite, placed in supine position.  general anesthetic was administered.  left arm was prepped and draped in appropriate manner.  a pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue.  utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop.  transverse graftotomy was created.  a #4 fogarty catheter passed proximally and distally restoring inflow and meager inflow.  a fistulogram was performed and the above findings were noted.  in a retrograde fashion, the proximal anastomosis was patent.  there was no narrowing within the forearm graft.  both veins were flushed with heparinized saline and controlled with a vascular clamp.  a longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia.  utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated.  the distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 prolene suture tied upon itself.  the vein was controlled with vascular clamps.  longitudinal venotomy created along the anteromedial wall.  a 7 mm graft was brought on to the field and this was cut to shape and size.  this was sewed to the graft in an end-to-side fashion with u-clips anchoring the graft at the heel and toe with interrupted #6-0 prolene sutures.  good backflow bleeding was confirmed.  the vein flushed with heparinized saline and graft was controlled with vascular clamp.  the end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 prolene suture.  good backflow bleeding was confirmed.  the graftotomy was then closed with interrupted #6-0 prolene suture.  flow through the fistula was permitted, a good flow passed.  the wound was copiously irrigated with antibiotic solution.  sponge, needles, instrument counts were correct.  all surgical sites were inspected.  good hemostasis was noted.  the incision was closed in layers with absorbable sutures.  sterile dressing was applied.  the patient tolerated the procedure well and returned to the recovery room in apparent stable condition.",19
"preoperative diagnoses:,1.  trimalleolar ankle fracture.,2.  dislocation right ankle.,postoperative diagnoses:,1.  trimalleolar ankle fracture.,2.  dislocation right ankle.,procedure performed: , closed open reduction and internal fixation of right ankle.,anesthesia:  ,spinal with sedation.,complications:  ,none.,estimated blood loss:  ,minimal.,total tourniquet time:  ,75 minutes at 325 mmhg.,components: , synthes small fragment set was used including a 2.5 mm drill bed.  a six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  there were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  there were two 4.0 cancellous partially-threaded screws placed.,gross findings:  ,include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,history of present illness: , the patient is an 87-year-old caucasian female who presented to abcd general hospital emergency room complaining of right ankle pain status post a trip and fall.  the patient noted while walking with a walker, apparently tripped and fell.  the patient had significant comorbidities, seen and evaluated by the emergency room department as well as department of orthopedics while in the emergency room.  at that time, a closed reduction was performed and she was placed in a robert-jones splint.  after complete medical workup and clearance, we elected to take her to the operating room for definitive care.,procedure:  ,after all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  the upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and department of anesthesia.  the patient was then transferred to preoperative area in the operative suite #3 and placed on the operating room table in supine position.  at this time, the department of anesthesia administered spinal anesthetic to the patient as well as sedation.  all bony prominences were well padded at this time.  a nonsterile tourniquet was placed on the right upper thigh of the patient.  this was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  the right lower extremity was then elevated and exsanguinated using esmarch and tourniquet was then placed to 325 mmhg and kept up to a total of 75 minutes.  next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  a sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  once the bone was reached, the fractured site was identified.  the bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  the wound was copiously irrigated and dried.  next, the fracture was then reduced in anatomic position.  there was noted to be quite a bit of comminution as well as soft overall status of the bone.  it was held in place with reduction forceps.  a six hole one-third tubular synthes plate was then selected for instrumentation.  it was contoured using ________ and placed on the lateral aspect of the distal fibula.  next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  the most proximal was a 12 mm and the next two were 16 mm in length.  next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  the most distal with a 20 mm and two most proximal were 18 mm in length.  next the xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  there was no lateralization of the joints.  attention was then directed towards the medial aspect of the ankle.  again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  again, the dissection was carefully taken down the level of the fracture site.  the retractors were then placed to protect all neurovascular structures.  once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  the fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  there appeared to be some minor degenerative changes of the talus, but no loose bodies.  next, the wound was copiously irrigated and suctioned dry.  the medial malleolus was placed in reduced position and held in place with a 1.25 mm k-wire.  next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  these appeared to hold the fracture site securely in an anatomic position.  again, xi-scan was brought in to confirm placement of the screws.  they were in good overall position and there was no lateralization of the joint.  at this time, each wound was copiously irrigated and suctioned dry.  the wounds were then closed using #2-0 vicryl suture in subcutaneous fashion followed by staples on the skin.  a sterile dressing was applied consistent with adaptic, 4x4s, kerlix, and webril.  a robert-jones style splint was then placed on the right lower extremity.  this was covered by a 4-inch depuy dressing.  at this time, the department of anesthesia reversed the sedation.  the patient was transferred back to the hospital gurney and to the postanesthetic care unit.  the patient tolerated the procedure well.  there were no complications.",25
"vital signs: , blood pressure *, pulse *, respirations *, temperature *.,general appearance:,  alert and in no apparent distress, calm, cooperative, and communicative.,heent: , eyes:  eomi.  perrla.  sclerae nonicteric.  no lesions of lids, lashes, brows, or conjunctivae noted.  funduscopic examination unremarkable.  ears:  normal set, shape, tms, canals and hearing.  nose and sinuses:  negative.  mouth, tongue, teeth, and throat:  negative except for dental work.,neck: , supple and pain free without bruit, jvd, adenopathy or thyroid abnormality.,chest:,  lungs are bilaterally clear to auscultation and percussion.,heart: , s1 and s2.  regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  pmi nondisplaced.  chest wall unremarkable to inspection and palpation.  no axillary or supraclavicular adenopathy detected.,breasts:,  in the seated and supine position unremarkable.,abdomen: , no hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  no widening of the aortic impulse and no intraabdominal bruit auscultated.,external genitalia: , normal for age.,rectal: , negative to 7 cm by gloved digital palpation with hemoccult-negative stool.,extremities: , good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  nails of the hands and feet, and creases of the palms and soles are unremarkable.  good active and passive range of motion of all major joints.,back:,  normal to inspection and percussion.  negative for spinous process tenderness or cva tenderness.  negative straight-leg raising, kernig, and brudzinski signs.,neurologic:,  nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  affect is normal.  speech is clear and fluent.  thought process is lucid and rational.  gait and station are unremarkable.,skin: , unremarkable for any premalignant or malignant condition with normal changes for age.",23
"referral indication and preprocedure diagnoses,1.  dilated cardiomyopathy.,2.  ejection fraction less than 10%.,3.  ventricular tachycardia.,4.  bradycardia with likely high degree of pacing.,procedures planned and performed,1.  implantation of biventricular automatic implantable cardioverter defibrillator.,2.  fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  coronary sinus venogram for left ventricular lead placement.,4.  defibrillation threshold testing x2.,fluoroscopy time:  ,18.5 minutes.,medications at the time of study,1.  vancomycin 1 g (the patient was allergic to penicillin).,2.  versed 10 mg.,3.  fentanyl 100 mcg.,4.  benadryl 50 mg.,clinical history: , the patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for aicd implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  he has underlying sinus bradycardia.  therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,risks and benefits:,  risks, benefits, and alternatives to implantation of biventricular aicd and defibrillation threshold testing were discussed with the patient.  risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  the patient agreed both verbally and via written consent.,description of procedure: , the patient was transported to the cardiac catheterization laboratory in the fasting state.  the region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  lidocaine 1% (20 ml) was administered to the area.  after achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  guidewires were advanced down into the left axillary vein.  following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  hemostasis was achieved with electrocautery.  lidocaine 1% (10 ml) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  using the more lateral of the guidewires, a 7-french side-arm sheath was advanced into the left axillary vein.  the dilator was removed and another wire was advanced down into the sheath.  the sheath was then backed up over the top of the two wires.  one wire was pinned to the drape and using the alternate wire, a 9-french side-arm sheath was advanced down into the left axillary vein.  the dilator and wire were removed.  a defibrillation lead was then advanced down into the atrium.  the peel-away sheath was removed.  the lead was then passed across the tricuspid valve and positioned in the apical septal location.  the active fix screw was deployed.  adequate pacing and sensing functions were established.  a 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  the suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  using the wire that had been pinned to the drape, a 7-french side-arm sheath was advanced over this wire into the axillary vein.  the wire and dilator were removed.  an active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  the lead was parked until a later time.  using the separate access point, a 9-french side-arm sheath was advanced into the left axillary vein.  the dilator and wire were removed.  a curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  the coronary sinus was cannulated.  inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  a coronary sinus venogram was then performed.  it was noted that the most suitable location for lead placement was the middle cardiac vein.  this was cannulated and a passive lead was advanced over a whisper eds wire into a distal position.  adequate pacing and sensing functions were established.  a 10-volt pacing was used temporarily.  there was no diaphragmatic stimulation.  the outer sheath was peeled away.  the 9 french sheath was then peeled away.  suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  at this point, the atrial lead was then positioned in the right atrial appendage using a preformed j-curved stylet.  the lead body was turned several times and the lead was affixed to the tissue.  adequate pacing and sensing function were established.  a suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  the pocket was then washed with antibiotic-impregnated saline.  pulse generator was obtained and connected securely to the leads.  the leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch.  sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,the patient was sedated further and shock on t was performed on two separate occasions.  the device was allowed to detect the charge and defibrillate, establishing the entire workings of the icd system.,device data,1.  pulse generator, manufacturer boston scientific, model # n119, serial #12345.,2.  right atrial lead, manufacturer guidant, model #4470, serial #12345.,3.  right ventricular lead, manufacturer guidant, model #0185, serial #12345.,4.  left ventricular lead, manufacturer guidant, model #4549, serial #12345.,measured intraoperative data,1.  right atrial lead impedance 705 ohms.  p-waves measured at 1.7 millivolts.  pacing threshold 0.5 volt at 0.4 milliseconds.,2.  right ventricular lead impedance 685 ohms.  r-waves measured 10.5 millivolts.  pacing threshold 0.6 volt at 0.4 milliseconds.,3.  left ventricular lead impedance 1098 ohms.  r-waves measured 5.2 millivolts.  pacing threshold 1.4 volts at 0.4 milliseconds.,defibrillation threshold testing,1.  shock on t.  charge time 2.9 seconds.  energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  shock on t.  charge time 2.8 seconds.  energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,device settings,1.  a pacing ddd 60 to 120.,2.  vt-1 zone 165 beats per minute.  vt-2 zone 185 beats per minute.  vf zone 205 beats per minute.,conclusions,1.  successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  defibrillation threshold of less than or equal to 17.5 joules.,2.  no acute complications.,plan,1.  the patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  chest x-ray to rule out pneumothorax and verified lead position.,3.  device interrogation in the morning.,4.  completion of the course of antibiotics.",2
"preoperative diagnosis:,  cecal polyp.,postoperative diagnosis: , cecal polyp.,procedure: , laparoscopic resection of cecal polyp.,complications: , none., ,anesthesia:  ,general oral endotracheal intubation.,procedure:,  after adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  blunt dissection was carried down to the fascia which was grasped with kocher clamps.  a bladed 11-mm port was inserted without difficulty.  pneumoperitoneum was obtained using c02.  under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  there was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  the cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  this was in what appeared to be an appropriate location for removal of this using the endo gia stapler without impinging on the ileocecal valve or the appendiceal orifice.  the appendix was somewhat retrocecal in position but otherwise looked normal.  the patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  there was enough however in the wall to identify the location of the polyp.  the lesion was grasped with a babcock clamp and an endo gia stapler used to fire across this transversely. the specimen was then removed through the 12-mm port and examined on the back table.  the lateral margin was found to be closely involved with the specimen so i did not feel that it was clear.  i therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  this new staple line was then opened on the back table and examined.  there was some residual polypoid material noted but the margins this time appeared to be clear.  the peritoneal cavity was then lavaged with antibiotic solution.  there were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  the trocars were removed under direct vision.  no bleeding was noted.  the bladed trocar site was closed using a figure-of-eight o vicryl suture.  all skin incisions were closed with running 4-0 monocryl subcuticular sutures.  mastisol and steri-strips were placed followed by sterile tegaderm dressing.  the patient tolerated the procedure well without any complications.",13
"history: , this patient with prenatal care in my office who did have some preterm labor and was treated with nifedipine and was stable on nifedipine and bed rest; unfortunately, felt decreased fetal movement yesterday, 12/29/08, presented to the hospital for evaluation on the evening of 12/29/08.  at approximately 2030 hours and on admission, no cardiac activity was noted by my on-call partner, dr. x.  this was confirmed by dr. y with ultrasound and the patient was admitted with a diagnosis of intrauterine fetal demise at 36 weeks' gestation.,summary:,  she was admitted.  she was 3 cm dilated on admission.  she desired induction of labor.  therefore, pitocin was started.  epidural was placed for labor pain.  she did have a temperature of 100.7 and antibiotics were ordered including gentamicin and clindamycin secondary to penicillin allergy.  she remained febrile, approximately 100.3.  she then progressed.  on my initial exam at approximately 0730 hours, she was 3 to 4 cm dilated.  she had reported previously some mucous discharge with no ruptured membranes.  upon my exam, no membranes were noted.  attempted artificial rupture of membranes was performed.  no fluid noted and there was no fluid discharge noted all the way until the time of delivery.  intrauterine pressure catheter was placed at that time to document there are adequate pressures on contraction secondary to induction of labor.  she progressed well and completely dilated, pushed approximately three times, and proceeded with delivery.,delivery note:,  delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise.  fetal position is right occiput anterior.,complications: , again, intrauterine fetal demise.  placenta delivery spontaneous.  condition was intact with a three-vessel cord.  lacerations; she had a small right periurethral laceration as well as a small second-degree midline laceration.  these were both repaired postdelivery with 4-0 vicryl on an sh and a 3-0 vicryl on a ct-1 respectively.  estimated blood loss was 200 ml.,infant is a male infant, appears grossly morphologically normal.  apgars were 0 and 0.  weight pending at this time.,narrative of delivery:,  i was called.  this patient was completely dilated.  i arrived.  she pushed for three contractions.  she was very comfortable.  she delivered the fetal vertex in the right occiput anterior position followed by the remainder of the infant.  there was a tight nuchal cord x1 that was reduced after delivery of the fetus.  cord was doubly clamped.  the infant was transferred to a bassinet cleaned by the nursing staff en route.  the placenta delivered spontaneously, was carefully examined, found to be intact.  no signs of abruption.  no signs of abnormal placentation or abnormal cord insertion.  the cord was examined and a three-vessel cord was confirmed.  at this time, iv pitocin and bimanual massage.  fundus firm as above with minimal postpartum bleeding.  the vagina and perineum were carefully inspected.  a small right periurethral laceration was noted, was repaired with a 4-0 vicryl on an sh needle followed by a small second-degree midline laceration, was repaired in a normal running fashion with a 3-0 vicryl suture.  at this time, the repair is intact.  she is hemostatic.  all instruments and sponges were removed from the vagina and the procedure was ended.,father of the baby has seen the baby at this time and the mother is waiting to hold the baby at this time.  we have called pastor in to baptize the baby as well as calling social work.  they are deciding on a burial versus cremation, have decided against autopsy at this time.  she will be transferred to postpartum for her recovery.  she will be continued on antibiotics secondary to fever to eliminate endometritis and hopefully will be discharged home tomorrow morning.,all of the care and findings were discussed in detail with christine and bryan and at this time obviously they are very upset and grieving, but grieving appropriately and understanding the findings and the fact that there is not always a known cause for a term fetal demise.  i have discussed with her that we will do some blood workup postdelivery for infectious disease profile and clotting disorders.",36
"title of procedure,creation of av fistula, left wrist in the anatomic snuffbox.,preoperative diagnosis,end-stage renal disease, need for chronic access.,postoperative diagnosis,end-stage renal disease, need for chronic access.,indication of the procedure,this 74-year-old lady was referred by dr. p for placement of an av fistula.  she has been on dialysis since december 2006 by a permcath placed in her right internal jugular vein.  she undergoes dialysis on monday, wednesday, and friday at davita in alameda and is under the care of dr. p.  she underwent coronary bypass surgery in 2000 and her cardiologist is dr. t.  she lives with her husband and she also has a son at home and she is a very active lady.  she is right handed.  the plan was to place an av fistula at the left wrist.  the risks and benefits were fully explained to her.  she elected to proceed as planned.,procedure in detail,in the operating room, under monitored anesthesia care with intravenous sedation, she was prepped and draped surgically.  lidocaine 1% was used for local anesthesia in the anatomic snuffbox at the left wrist.  the cephalic vein was exposed.  the superficial branch of the radial artery was carefully protected and the radial artery was exposed.  there was moderate calcification of the radial artery.,the patient was heparinized and end-to-side anastomosis was performed between the cephalic vein and radial artery using a 7-0 prolene suture.  there was an excellent doppler signal in the cephalic vein all the way up the arm upon completion.,the wound was closed using absorbable suture and she was transferred to recovery.  there were no complications.",36
"preoperative diagnoses:  ,1.  congenital chylous ascites and chylothorax.,2.  rule out infradiaphragmatic lymphatic leak.,postoperative diagnoses: , diffuse intestinal and mesenteric lymphangiectasia.,anesthesia: , general.,indication:  ,the patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  the patient has been treated somewhat successfully with tpn and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  last week, dr. x took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  however at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  dr. x opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  this was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  we met with his parents and talked to them about this, and he is here today for that attempt.,operative findings:  ,the patient's abdomen was relatively soft, minimally distended.  exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  what we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  it appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  there was about one quarter to one third of the jejunum that did not appear to be grossly involved, but i did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,the lymphatic abnormality was extensive.  they were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  they were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  no other major retroperitoneal structure or correctable structure was identified.  both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,description of operation:  ,the patient was brought from the pediatric intensive care unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  we conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  as the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  the bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  the small bowel from the ligament of treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for the patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  we suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 pds on the posterior sheath and 3-0 pds on the anterior rectus sheath.  subcuticular 5-0 monocryl and steri-strips were used for skin closure.,the patient tolerated the procedure well.  he lost minimal blood, but did lose approximately 100 ml of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  the patient was returned to the pediatric intensive care unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an intestinal transplantation center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.",36
"preoperative diagnosis and indications:,  acute non-st-elevation mi.,postoperative diagnosis and summary:,  the patient presented with an acute non-st-elevation mi.  despite medical therapy, she continued to have intermittent angina.  angiography demonstrated the severe lad as the culprit lesion.  this was treated as noted above with angioplasty alone as the stent could not be safely advanced.  she has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual lad lesions as noted above.  she will be continued on her medical therapy.  at age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,procedure performed: , selective coronary angiography, coronary angioplasty.,procedure in detail:,  after informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  the area of the right femoral artery was prepped and draped in a sterile fashion.  using the percutaneous technique, a 6-french sheath was placed in the right femoral artery under fluoroscopic guidance.  with the guidewire in place, a 5-french jl-4 catheter was used to selectively angiogram the left coronary system.  the catheter was removed.  the sheath flushed.  the 5-french 3drc catheter was then used to selectively angiogram the right coronary artery.  the cath removed, the sheath flushed.,it was decided that intervention was needed in the severe lesions in the lad, which appeared to be the culprit lesions for the non-st elevation-mi.  the patient was given a bolus of heparin and an act of approximately 50 seconds was obtained, we rebolused and the act was slightly lower.  we repeated the level and it was slightly higher.  we administered 500 more units of heparin and then proceeded with an act of approximately 270 seconds prior to the 500 units of heparin iv.  additionally, the patient had been given 300 mg of plavix orally during the procedure and integrilin iv bolus and then maintenance drip was started.,a 6-french cls 3.5 left coronary guide catheter was used to cannulate the left main and hew guidewire was positioned in the distal lad and another hew guidewire in the relatively large third diagonal.  an apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid lad stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  the balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  the balloon was inflated and removed, repeat angiography performed.  we attempted to advance a driver 2.5 x 24 mm bare metal stent, but i could not advance it beyond the proximal lad, where there was significant calcification.  the stent was removed.  attempts to advance the same 2.5 x 15 mm apex balloon that was previously used were unsuccessful.  it was removed, a new apex 2.5 x 15 mm balloon was then positioned in the proximal lad and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  repeat angiography demonstrated no evidence of dissection.  one more attempt was made to advance the driver 2.5 x 24 mm bare metal stent, but again i could not advance it beyond the calcified plaque in the proximal lad and this was despite the presence of the buddy wire in the diagonal.  i felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  the guidewires and guide cath were removed.  the sheath flushed and sutured into position.  the patient moved to icu in stable condition with no chest discomfort at all.,contrast: , isovue-370, 120 ml.,fluoro time: , 9.4 minutes.,estimated blood loss: , 30 ml.,hemodynamics:,  aorta 185/54.,left ventriculography was not performed.  i did not make an attempt to cross this severely stenotic aortic valve.,the left main is a large vessel, giving rise to lad and circumflex vessels.  the left main has no significant disease other than calcification in the walls.,the lad is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  the lad has significant calcification proximally.  there is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  this resulted in a 30% residual, mostly eccentric calcified plaque.  following this, there was a 50% stenosis in the lad just after the takeoff of the third diagonal.  this was not ballooned.  beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  these 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  as noted above, this area was not stented because i could not safely advance the stent.  note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,the circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  the proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  the remainder of the vessel was without significant disease.,the right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  the right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  the remainder of the right coronary and its branches were without significant disease.",36
"cc: ,ble weakness and numbness.,hx:, this 59 y/o rhm was seen and released from an er 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. he reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. on presentation, he felt numb from the nipple line down. in addition, he began experiencing progressive weakness in his lower extremities for the past week. he started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. he claimed he could not stand. he denied loss of bowel or bladder control. however, he had not had a bowel movement in 3 days and he had not urinated 24 hours. his lower extremities had been feeling cold for a day. he denied any associated back or neck pain. he has chronic shortness of breath, but felt it had become worse. he had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,pmh:, 1)cad with chronic cp, 2)nqwmi 1994, s/p coronary angioplasty, 3)copd (previous fev 11.48, and fvc 2.13), 4)anxiety d/o, 5)djd, 6)developed confusion with metoprolol use, 7)htn.,meds:, benadryl, ecasa, diltiazem, isordil, enalapril, indomethacin, terbutaline mdi, ipratropium mdi, folic acid, thiamine.,shx:, 120pk-yr smoking, etoh abuse in past, retired dock hand,fhx: ,unremarkable except for etoh abuse,exam:,  t98.2 96bpm 140/74mmhg r18,thin cachetic male in moderate distress.,ms: a&o to person, place and time. speech was fluent and without dysarthria. comprehension, naming and reading were intact.,cn: unremarkable.,motor: full strength in both upper extremities.,hf he hadd habd kf ke af ae,rle 3 3 4 4 3 4 1 1,lle 4 4 4+ 4+ 4+ 4 4 4,there was mild spastic muscle tone in the lower extremities. there was normal muscle bulk throughout.,sensory: decreased pp in the lle from the foot to nipple line, and in the rle from the knee to nipple line. decreased temperature sensation from the feet to the umbilicus, bilaterally. no loss of vibration or proprioception. decreased light touch from the feet to nipple line, bilaterally.,gait: unable to walk. stands with support only.,station: no pronator drift or truncal ataxia.,reflexes: 2+/2+ in bue, 3+/3+ patellae, 0/1 ankles. babinski signs were present, bilaterally. the abdominal reflexes were absent.,cv: rrr with a 2/6 systolic ejection murmur at the left sternal border. lungs: cta with mildly labored breathing. abdomen: nt, nd, nbs, but bladder distended. extremities were cool to touch. peripheral pulses were intact and capillary refill was brisk. rectal: decreased rectal tone and absent anal reflex. right prostate nodule at the inferior pole.,course: ,admission labs: fev1=1.17, fvc 2.19, abg 7.39/42/79 on room air. wbc 10/5, hgb 13, hct 39, electrolytes were normal. pt & ptt were normal. straight catheterization revealed a residual volume of 400cc of urine.,he underwent emergent t-spine mri. this revealed a t3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. he was treated with decadron and underwent emergent spinal cord decompression on 5/7/95. he recovered some lower extremity strength following surgery. pathological analysis of the tumor was consistent with adenocarcinoma. his primary tumor was not located despite chest-abdominal-pelvic ct scans, and a gi and gu workup which included cystoscopy and endoscopy. he received 3000cgy of xrt and died 5 months after presentation.",20
"procedure:,  upper endoscopy with biopsy.,procedure indication: , this is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  an endoscopy is being done to evaluate for source of upper gi bleeding.,informed consent was obtained.  outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,medications: , versed 4 mg iv push and fentanyl 75 mcg iv push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,procedure in detail:  ,the patient was placed in the left lateral decubitus position.  medications were given.  after adequate sedation was achieved, the olympus video endoscope was inserted into the mouth and advanced towards the duodenum.",13
"preoperative diagnosis: , acute infected olecranon bursitis, left elbow.,postoperative diagnosis: , infection, left olecranon bursitis.,procedure performed:,1.  incision and drainage, left elbow.,2.  excision of the olecranon bursa, left elbow.,anesthesia: , local with sedation.,complications: , none.,needle and sponge count: , correct.,specimens: , excised bursa and culture specimens sent to the microbiology.,indication:  ,the patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  he was then scheduled for i&d and excision of the bursa.  risks and benefits were discussed.  no guarantees were made or implied.,procedure: , the patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain marcaine.  the left upper extremity was prepped and draped in standard sterile fashion.  on examination of the left elbow, there was presence of thickening of the bursal sac.  there was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  an incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  the incision was carried proximally and distally.  the olecranon bursa was significantly thickened and scarred.  excision of the olecranon bursa was performed.  there was significant evidence of thickening of the bursa with some evidence of adhesions.  satisfactory olecranon bursectomy was performed.  the wound margins were debrided.  the wound was thoroughly irrigated with pulsavac irrigation lavage system mixed with antibiotic solution.  there was no evidence of a loose body.  there was no bleeding or drainage.  after completion of the bursectomy and i&d, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  the open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  sterile dressings were placed including xeroform, 4x4, abd, and bias.  the patient tolerated the procedure very well.  he was then extubated and transferred to the recovery room in a stable condition.  there were no intraoperative complications noticed.",25
"preoperative diagnosis: , left carpal tunnel syndrome.,postoperative diagnosis:,  left carpal tunnel syndrome.,operative procedure performed:,  left carpal tunnel release.,findings:,  showed severe compression of the median nerve on the left at the wrist.,specimens:  ,none.,fluids:,  500 ml of crystalloids.,urine output:,  no foley catheter.,complications: , none.,anesthesia: , general through a laryngeal mask.,estimated blood loss: , none.,condition: , resuscitated with stable vital signs.,indication for the operation: , this is a case of a very pleasant 65-year-old forensic pathologist who i previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at c5-6 and c6-7 with spinal instrumentation.  at the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now.  operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia.  there is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection.  he understood this risk and agreed to have the procedure performed.,description of the procedure: , the patient was brought to the operating room, awake, alert, not in any form of distress.  after smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table.  the left upper extremity was then prepped with betadine soap and antiseptic solution.  after sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmhg.  clamp time approximately 30 minutes.  an incision was then made right in the mid palm area between the thenar and hypothenar eminence.  meticulous hemostasis of any bleeders were done.  the fat was identified.  the palmar aponeurosis was identified and cut and this was traced down to the wrist.  there was severe compression of the median nerve.  additional removal of the aponeurosis was performed to allow for further decompression.  after this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using prolene 4-0 as interrupted vertical mattress stitches.  dressing was applied.  the patient was brought to the recovery.",25
"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.",31
"preoperative diagnosis:  ,tracheal stenosis and metal stent complications.,postoperative diagnosis:  ,tracheal stenosis and metal stent complications.,anesthesia:  ,general endotracheal.,endoscopic findings:,1.  normal true vocal cords.,2.  subglottic stenosis down to 5 mm with mature cicatrix.,3.  tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  three metallic stents in place in the proximal trachea.,6.  distance from the true vocal cords to the proximal stent, 2 cm.,7.  distance from the proximal stent to the distal stent, 3.5 cm.,8.  distance from the distal stent to the carina, 8 cm.,9.  distal airway is clear.,procedures:,1.  rigid bronchoscopy with dilation.,2.  excision of granulation tissue tumor.,3.  application of mitomycin-c.,4.  endobronchial ultrasound.,technique in detail:  ,after informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  she had a dedo laryngoscope placed.  her airways were inspected thoroughly with findings as described above.  she was intermittently ventilated with an endotracheal tube placed through the dedo scope.  her granulation tissue was biopsied and then removed with a microdebrider.  her proximal trachea was dilated with a combination of balloon, bougie, and rigid scopes.  she tolerated the procedure well, was extubated, and brought to the pacu.",2
"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.",4
"chief complaint:  ,leaking nephrostomy tube.,history of present illness: , this 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  the leaking began this a.m.  the patient denies any pain, does not have fever and has no other problems or complaints.  the patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  the patient states he feels like his usual self and has no other problems or concerns.  the patient denies any fever or chills.  no nausea or vomiting.  no flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,review of systems: , review of systems otherwise negative and noncontributory.,past medical history: , metastatic prostate cancer, anemia, hypertension.,medications: , medication reconciliation sheet has been reviewed on the nurses' note.,allergies: , no known drug allergies.,social history: , the patient is a nonsmoker.,physical examination:  ,vital signs:  temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  constitutional:  the patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  heent:  eyes are normal with clear sclerae and cornea.  neck:  supple, full range of motion.  cardiovascular:  heart has regular rate and rhythm without murmur, rub or gallop.  peripheral pulses are +2.  no dependent edema.  respirations:  clear to auscultation bilaterally.  no shortness of breath.  no wheezes, rales or rhonchi.  good air movement bilaterally.  gastrointestinal:  abdomen is soft, nontender, nondistended.  no rebound or guarding.  normal benign abdominal exam.  musculoskeletal:  the patient has nontender back and flank.  no abnormalities noted to the back other than the bilateral nephrostomy tubes.  the nephrostomy tube left has no abnormalities, no sign of infection.  no leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  there is no obvious active leak from the ostomy site.  no sign of infection.  no erythema, swelling or tenderness.  the collection bag is full of clear urine.  the patient has no abnormalities on his legs.  skin:  no rashes or lesions.  no sign of infection.  neurologic:  motor and sensory are intact to the extremities.  the patient has normal ambulation, normal speech.  psychiatric:  alert and oriented x4.  normal mood and affect.  hematologic and lymphatic:  no bleeding or bruising.,emergency department course:,  reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both dr. x and dr. y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  there was no consultation dictated for this and no name was mentioned in the discharge summary, paged dr. x as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  dr. a responded to the page and recommended __________ off a bmp and discussing it with dr. b, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged dr. x and received a call back from dr. x.  dr. x stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  this was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by dr. x was explained and understood.,diagnoses:,1.  weak nephrostomy site for the right nephrostomy tube.,2.  prostate cancer, metastatic.,3.  ureteral obstruction.,the patient on discharge is stable and dispositioned to home.,plan: , we will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by dr. x.  the patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.",19
"chief complaint: , blood in urine.,history of present illness:  ,this is a 78-year-old male who has prostate cancer with metastatic disease to his bladder and in several locations throughout the skeletal system including the spine and shoulder.  the patient has had problems with hematuria in the past, but the patient noted that this episode began yesterday, and today he has been passing principally blood with very little urine.  the patient states that there is no change in his chronic lower back pain and denies any incontinence of urine or stool.  the patient has not had any fever.  there is no abdominal pain and the patient is still able to pass urine.  the patient has not had any melena or hematochezia.  there is no nausea or vomiting.  the patient has already completed chemotherapy and is beyond treatment for his cancer at this time.  the patient is receiving radiation therapy, but it is targeted to the bones and intended to give symptomatic relief of his skeletal pain and not intended to treat and cure the cancer.  the patient is not enlisted in hospice, but the principle around the patient's current treatment management is focusing on comfort care measures.,review of systems: , constitutional:  no fever or chills.  the patient does report generalized fatigue and weakness over the past several days.  heent:  no headache, no neck pain, no rhinorrhea, no sore throat.  cardiovascular:  no chest pain.  respirations:  no shortness of breath or cough, although the patient does get easily winded with exertion over these past few days.  gastrointestinal:  the patient denies any abdominal pain.  no nausea or vomiting.  no changes in the bowel movement.  no melena or hematochezia.  genitourinary:  a gross hematuria since yesterday as previously described.  the patient is still able to pass urine without difficulty.  the patient denies any groin pain.  the patient denies any other changes to the genital region.  musculoskeletal:  the chronic lower back pain which has not changed over these past few days.  the patient does have multiple other joints, which cause him discomfort, but there have been no recent changes in these either.  skin:  no rashes or lesions.  no easy bruising.  neurologic:  no focal weakness or numbness.  no incontinence of urine or stool.  no saddle paresthesia.  no dizziness, syncope or near-syncope.  endocrine:  no polyuria or polydipsia.  no heat or cold intolerance.  hematologic/lymphatic:  the patient does not have a history of easy bruising or bleeding, but the patient has had previous episodes of hematuria.,past medical history: , prostate cancer with metastatic disease as previously described.,past surgical history: , turp.,current medications:,  morphine, darvocet, flomax, avodart and ibuprofen.,allergies: , vicodin.,social history: , the patient is a nonsmoker.  denies any alcohol or illicit drug use.  the patient does live with his family.,physical examination: , vital signs:  temperature is 98.8 oral, blood pressure is 108/65, pulse is 109, respirations 16, oxygen saturation is 97% on room air and interpreted as normal.  constitutional:  the patient is well nourished, well developed.  the patient appears to be pale, but otherwise looks well.  the patient is calm, comfortable.  the patient is pleasant and cooperative.  heent:  eyes normal with clear conjunctivae and corneas.  nose is normal without rhinorrhea or audible congestion.  mouth and oropharynx normal without any sign of infection.  mucous membranes are moist.  neck:  supple.  full range of motion.  no jvd.  cardiovascular:  heart is mildly tachycardic with regular rhythm without murmur, rub or gallop.  peripheral pulses are +2.  respirations:  clear to auscultation bilaterally.  no shortness of breath.  no wheezes, rales or rhonchi.  good air movement bilaterally.  gastrointestinal:  abdomen is soft, nontender, nondistended.  no rebound or guarding.  no hepatosplenomegaly.  normal bowel sounds.  no bruit.  no masses or pulsatile masses.  genitourinary:  the patient has normal male genitalia, uncircumcised.  there is no active bleeding from the penis at this time.  there is no swelling of the testicles.  there are no masses palpated to the testicles, scrotum or the penis.  there are no lesions or rashes noted.  there is no inguinal lymphadenopathy.  normal male exam.  musculoskeletal:  back is normal and nontender.  there are no abnormalities noted to the arms or legs.  the patient has normal use of the extremities.  skin:  the patient appears to be pale, but otherwise the skin is normal.  there are no rashes or lesions.  neurologic:  motor and sensory are intact to the extremities.  the patient has normal speech.  psychiatric:  the patient is alert and oriented x4.  normal mood and affect.  hematologic/lymphatic:  there is no evidence of bruising noted to the body.  no lymphadenitis is palpated.,emergency department testing:,  cbc was done, which had a hemoglobin of 7.7 and hematocrit of 22.6.  neutrophils were 81%.  the rdw was 18.5, and the rest of the values were all within normal limits and unremarkable.  chemistry had a sodium of 134, a glucose of 132, calcium is 8.2, and rest of the values are unremarkable.  alkaline phosphatase was 770 and albumin was 2.4.  rest of the values all are within normal limits of the lfts.  urinalysis was grossly bloody with a large amount of blood and greater than 50 rbc's.  the patient also had greater than 300 of the protein reading, moderate leukocytes, 30-50 white blood cells, but no bacteria were seen.  coagulation profile study had a pt of 15.9, ptt of 43 and inr of 1.3.,emergency department course: , the patient was given normal saline 2 liters over 1 hour without any adverse effect.  the patient was given multiple doses of morphine to maintain his comfort while here in the emergency room without any adverse effect.  the patient was given levaquin 500 mg by mouth as well as 2 doses of phenergan over the course of his stay here in the emergency department.  the patient did not have an adverse reaction to these medicines either.  phenergan resolved his nausea and morphine did relieve his pain and make him pain free.  i spoke with dr. x, the patient's urologist, about most appropriate step for the patient, and dr. x said he would be happy to care for the patient in the hospital and do urologic scopes if necessary and surgery if necessary and blood transfusion.  it was all a matter of what the patient wished to do given the advanced stage of his cancer.  dr. x was willing to assist in any way the patient wished him to.  i spoke with the patient and his son about what he would like to do and what the options were from doing nothing from keeping him comfortable with pain medicines to admitting him to the hospital with the possibility of scopes and even surgery being done as well as the blood transfusion.  the patient decided to choose a middle ground in which he would be transfused with 2 units of blood here in the emergency room and go home tonight.  the patient's son felt comfortable with his father's choice.  this was done.  the patient was transfused 2 units of packed red blood cells after appropriately typed and match.  the patient did not have any adverse reaction at any point with his transfusion.  there was no fever, no shortness of breath, and at the time of disposition, the patient stated he felt a little better and felt like he had a little more strength.  over the course of the patient's several-hour stay in the emergency room, the patient did end up developing enough problems with clotted blood in his bladder that he had a urinary obstruction.  foley catheter was placed, which produced bloody urine and relieved the developing discomfort of a full bladder.  the patient was given a leg bag and the foley catheter was left in place.,diagnoses,1.  hematuria.,2.  prostate cancer with bone and bladder metastatic disease.,3.  significant anemia.,4.  urinary obstruction.,condition on disposition:  ,fair, but improved.,disposition: , to home with his son.,plan: , we will have the patient follow up with dr. x in his office in 2 days for reevaluation.  the patient was given a prescription for levaquin and phenergan tablets to take home with him tonight.  the patient was encouraged to drink extra water.  the patient was given discharge instructions on hematuria and asked to return to the emergency room should he have any worsening of his condition or develop any other problems or symptoms of concern.",37
"reason for visit: , followup circumcision.,history of present illness: , the patient had his circumcision performed on 09/16/2007 here at children's hospital.  the patient had a pretty significant phimosis and his operative course was smooth.  he did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  his mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  he is having no difficulty urinating, and his bowel function remains normal.,physical examination:  ,today, the patient looks healthy and happy.  we examined his circumcision site.  his monocryl sutures are still in place.  the healing is excellent, and there is only a mild amount of residual postoperative swelling.  there was one area where he had some recurrent adhesions at the coronal sulcus, and i gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,impression: , satisfactory course after circumcision for severe phimosis with no perioperative complications.,plan:  ,the patient came in followup for his routine care with dr. x, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  if that does occur, we will be happy to see him back at any time.,",37
"exam:,mri left shoulder,clinical:,this is a 26 year old with a history of instability. examination was preformed on 12/20/2005.,findings:,there is supraspinatus tendinosis without a full-thickness tear, gap or fiber retraction and there is no muscular atrophy (series #105 images #4-6).,normal infraspinatus and subscapularis tendons.,normal long biceps tendon within the bicipital groove. there is medial subluxation of the tendon under the transverse humeral ligament, and there is tendinosis of the intracapsular portion of the tendon with partial tearing, but there is no complete tear or discontinuity. biceps anchor is intact (series #105 images #4-7; series #102 images #10-22).,there is a very large hill-sachs fracture, involving almost the entire posterior half of the humeral head (series #102 images #13-19). this is associated with a large inferior bony bankart lesion that measures approximately 15 x 18mm in ap and craniocaudal dimension with impaction and fragmentation (series #104 images #10-14; series #102 images #18-28). there is medial and inferior displacement of the fragment. there are multiple interarticular bodies, some of which may be osteochondromatous and some may be osseous measuring up to 8mm in diameter. (these are too numerous to count.) there is marked stretching, attenuation and areas of thickening of the inferior and middle glenohumeral ligaments, compatible with a chronic tear with scarring but there is no discontinuity or demonstrated hagl lesion (series #105 images #5-10).,normal superior glenohumeral ligament.,there is no slap tear.,normal acromioclavicular joint without narrowing of the subacromial space.,normal coracoacromial, coracohumeral and coracoclavicular ligaments.,there is fluid in the glenohumeral joint and biceps tendon sheath.,impression:,there is a very large hill-sachs fracture involving most of the posterior half of the humeral head with an associated large and inferior and medial displaced osseous bankart lesion.,there are multiple intraarticular bodies, and there is a partial tear of the inferior and middle glenohumeral ligaments.,there is medial subluxation of the long biceps tendon under the transverse humeral ligament with partial tearing of the intracapsular portion.,",31
"reason for admission: , hepatic encephalopathy.,history of present illness: , the patient is a 51-year-old native american male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  he said that he was doing fine prior to that and denied having any complaints.  he was sitting watching tv and he felt sleepy.  so, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  his head hit the toilet seat.  then, he started having bleeding and had pain in the area with headache.  he did not lose consciousness as far as he can tell.  he went and woke up his sister.  this happened somewhere between 10:30 and 11 p.m.  his sister brought a towel and covered the laceration on the back of his head and called ems, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a ct of the head was obtained and ruled out any acute intracranial pathology.  on his lab work, his ammonia was found to be markedly elevated at 106.  so, he is being admitted for management of this.  he denied having any abdominal pain, change in bowel habits, gi bleed, hematemesis, melena, or hematochezia.  he said he has been taking his medicines, but he could not recall those.  he denied having any symptoms prior to this fall.  he said earlier today he also fell.  he also said that this was an accidental fall caused by problem with his walker.  he landed on his back at that time, but did not have any back pain afterwards.,past medical history:,1.  liver cirrhosis caused by alcohol.  this is per the patient.,2.  he thinks he is diabetic.,3.  history of intracranial hemorrhage.  he said it was subdural hematoma.  this was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  he said he had a seizure back then, but he does not have seizures now.,past surgical history:,1.  he has a surgery on his stomach as a child.  he does not know the type.,2.  surgery for a leg fracture.,3.  craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,medications: , he does not remember his medications except for the lactulose and multivitamins.,allergies: , dilantin.,social history: , he lives in sacaton with his sister.  he is separated from his wife who lives in coolidge.  he smokes one or two cigarettes a day.  denies drug abuse.  he used to be a heavy drinker, quit alcohol one year ago and does not work currently.,family history:,  negative for any liver disease.,review of systems:,general:  denies fever or chills.  he said he was in gilbert about couple of weeks ago for fever and was admitted there for two days.  he does not know the details.,ent:  no visual changes.  no runny nose.  no sore throat.,cardiovascular:  no syncope, chest pain, or palpitations.,respiratory:  no cough or hemoptysis.  no dyspnea.,gi:  no abdominal pain.  no nausea or vomiting.  no gi bleed.  history of alcoholic liver disease.,gu:  no dysuria, hematuria, frequency, or urgency.,musculoskeletal:  denies any acute joint pain or swelling.,skin:  no new skin rashes or itching.,cns:  had a seizure many years ago with no recurrences.  left-sided hemiparesis after subdural hematoma from a fight/trauma.,endocrine:  he thinks he has diabetes but does not know if he is on any diabetic treatment.,physical examination:,vital signs:  temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,general:  the patient is lying in bed, appears comfortable, very pleasant native american male in no apparent distress.,heent:  his skull has a scar on the left side from previous surgery.  on the back of his head, there is a laceration, which has two staples on.  it is still oozing minimally.  it is tender.  no other traumatic injury is noted.  eyes, pupils react to light.  sclerae anicteric.  nostrils are normal.  oral cavity is clear with no thrush or exudate.,neck:  supple.  trachea midline.  no jvd.  no thyromegaly.,lymphatics:  no cervical or supraclavicular lymphadenopathy.,lungs:  clear to auscultation bilaterally.,heart:  normal s1 and s2.  no murmurs or gallops.  regular rate and rhythm.,abdomen:  soft, distended, nontender.  no organomegaly or masses.,lower extremities:  +1 edema bilaterally.  pulses strong bilaterally.  no skin ulcerations noted.  no erythema.,skin:  several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,back:  no tenderness by exam.,rectal:  no masses.  no abscess.  no rectal fissures.  guaiac was performed by me and it was negative.,neurologic:  he is alert and oriented x2.  he is slow to some extent in his response.  no asterixis.  right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  increased tone noted in upper and lower extremities on the right compared to the left.  deep tendon reflexes are +3 on the right and +2 on the left.  muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  the upper extremity is +4/5.  lower extremity is 3/5.  the left side has a normal strength.  sensation appears to be intact.  babinski is upward on the right, equivocal on the left.,psychiatric:  flat affect.  mood appeared to be appropriate.  no active hallucinations or psychotic symptoms.,laboratory data: ",20
"exam:,  mri head without contrast.,reason for exam: , severe headaches.,interpretation:,  imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  correlation is made with the head ct of 4/18/05.,on the diffusion sequence, there is no significant bright signal to indicate acute infarction.  there is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  there is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  there are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  there is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent ct scan.  this involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  no abnormal mass effect is identified.  there are no findings to suggest active hydrocephalus.  no abnormal extra-axial collection is identified.  there is normal flow void demonstrated in the major vascular systems.,the sagittal sequence demonstrates no chiari malformation.  the region of the pituitary/optic chiasm grossly appears normal.  the mastoids and paranasal sinuses are clear.,impression:,1.  no definite acute findings identified involving the brain.,2.  there is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  there is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  moderate to moderately advanced atrophy.",20
"operation performed:  ,dental prophylaxis under general anesthesia.,preoperative diagnoses:,1.  impacted wisdom teeth.,2.  moderate gingivitis.,postoperative diagnoses:,1.  impacted wisdom teeth.,2.  moderate gingivitis.,complications:  ,none.,estimated blood loss:  ,minimal.,duration of surgery:  ,one hour 17 minutes.,brief history:  ,the patient was referred to me by dr. x.  he contacted myself and stated that angelica was going to have her wisdom teeth extracted in the setting of a hospital operating room at hospital and he inquired if we could pair on the procedure and i could do her full mouth dental rehabilitation before the wisdom teeth were removed by him.  i agreed.  i saw her in my office and she was cooperative for full mouth set of radiographs in my office and a clinical examination.  this clinical and radiographic examination revealed no dental caries; however, she was in need of a good dental cleaning.,operative preparation:  ,the patient was brought to hospital day surgery accompanied by her mother.  i met with them and discussed the needs of the child, types of restoration to be performed, and the risks and benefits of the treatment as well as the options and alternatives of the treatment.  after all their questions and concerns were addressed, they gave their informed consent to proceed with the treatment.  the patient's history and physical examination was reviewed.  once she was cleared by anesthesia, she was taken back to the operating room.,operative procedure:  ,the patient was placed on the surgical table in the usual supine position with all extremities protected.  anesthesia was induced by mask.  the patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  the head was wrapped and the eyes were taped shut for protection.  an angiocath was previously placed in preop.  the head and neck were draped in sterile towels, and the body was covered with lead apron and sterile sheath.  a moist continuous throat pack was placed beyond tonsillar pillars.  plastic lip and cheek retractors were then placed.  preoperative digital intraoral photographs were taken.  no digital radiographs were taken in the operating room, as i stated before i had a full set of digital radiographs taken in my office.  a prophylaxis was then performed using a prophy cup and fluoridated prophy paste after scaling and replaning was done.  she presented with moderate calculus on the buccal surfaces of her maxillary, first molars and lower molars.  she did not require any restorative dentistry.,upon the conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  the original treatment plan was verified with the actual treatment provided.  postoperative clinical photographs were taken.  the continuous gauze throat pack was removed with continuous suction and visualization.  topical fluoride was then placed on the teeth.,at the end of the procedure, the child was undraped, extubated, and awakened in the operating room, taken to the recovery room, breathing spontaneously with stable vital signs.,findings: , this patient presented in her permanent dentition.  her teeth #1, 16, 17, and 32 were impacted and are going to be removed following my full mouth dental rehabilitation by dr. alexander.  oral hygiene was fair.  there was generalized plaque and calculus throughout.  she did not have any caries, did not require any restorative dentistry.,conclusion:,  following my dental surgery, the patient continued to intubated and was prepped for oral surgery procedures by dr. x and his associates.  there were no postop pain requirements.  i did not have any specific requirements for the patient or her mother and that will be handled by dr. x and their instructions on soft foods, etc., and pain control will be managed by them.",36
"medications:,1.  versed intravenously.,2.  demerol intravenously.,description of the procedure: , after informed consent, the patient was placed in the left lateral decubitus position and cetacaine spray was applied to the posterior pharynx.  the patient was sedated with the above medications.  the olympus video panendoscope was advanced under direct vision into the esophagus.  the esophagus was normal in appearance and configuration.  the gastroesophageal junction was normal.  the scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  the gastric mucosa appeared normal.  the pylorus was normal.  the scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  the scope was pulled back into the stomach.  retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  the scope was straightened out, the air removed and the scope withdrawn.  the patient tolerated the procedure well.  there were no apparent complications.,",36
"subjective:,  this patient was seen in clinic for a school physical.,nutritional history:,  she eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  she does not drink a whole lot of pop.  her stools are normal.  brushes her teeth, sees a dentist.,developmental history:  hearing and vision is okay.  she did well in school last year.  she will be going to move to texas, will be going to bowie high school.  she will be involved in cheerleading, track, volleyball, and basketball.  she will be also playing the clarinet and will be a freshman in that school.  her menarche was 06/30/2004.,past medical history:,  she is still on medications for asthma.  she has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  she had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,review of her immunizations, her last tetanus shot was 06/17/2003.,medications:  ,advair 100/50 b.i.d., allegra 60 mg b.i.d., flonase q.d., xopenex, intal, and albuterol p.r.n.,allergies: , no known drug allergies.,objective:,vital signs:  weight:  112 pounds about 40th percentile.  height:  63-1/4 inches, also the 40th percentile.  her body mass index was 19.7, 40th percentile.  temperature:  97.7 tympanic.  pulse:  80.  blood pressure:  96/64.,heent:  normocephalic.  fundi benign.  pupils equal and reactive to light and accommodation.  no strabismus.  her vision was 20/20 in both eyes and each with contacts.  hearing:  she passed that test.  her tms are bilaterally clear and nonerythematous.  throat was clear.  good mucous membrane moisture and good dentition.,neck:  supple.  thyroid normal sized.  no increased lymphadenopathy in the submandibular nodes and no axillary nodes.,abdomen:  no hepatosplenomegaly.,respiratory:  clear.  no wheezes.  no crackles.  no tachypnea.  no retractions.,cardiovascular:  regular rate and rhythm.  s1 and s2 normal.  no murmur.,abdomen:  soft.  no organomegaly and no masses.,gu:  normal female genitalia.  tanner stage 3, breast development and pubic hair development.  examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,extremities:  she has good range of motion of upper and lower extremities.  deep tendon reflexes were 2+/4+ bilaterally and equal.  romberg negative.,back:  no scoliosis.  she had good circumduction at shoulder joint and her duck walk was normal.,skin:  she did have some rash on the anterior left thigh region and also some on the right lower leg that had kebner phenomenon and maculopapular vesicular eruption.  no honey crusting was noted on the skin.  she also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  it was raised and blanch with pressure, it was slightly erythematous.,assessment and plan:,1.  sports physical.,2.  the patient received her first hepatitis a vaccine.  she will get a booster in 6 to 12 months.  prescription for atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for elocon ointment to be applied topically, except for the face, once a day with a refill.  she will be following up with an allergist as soon as she gets to texas and needs to find a primary care physician.  we talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  we talked about avoidance of drugs and alcohol and sexual activity.  continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on po steroid medication, but presently that was held and moved to treatment with atarax and elocon.  also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.",27
"review of systems:,constitutional:  patient denies fevers, chills, sweats and weight changes.,eyes:  patient denies any visual symptoms.,ears, nose, and throat:  no difficulties with hearing.  no symptoms of rhinitis or sore throat.,cardiovascular:  patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,respiratory:  no dyspnea on exertion, no wheezing or cough.,gi:  no nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,gu:  no urinary hesitancy or dribbling.  no nocturia or urinary frequency.  no abnormal urethral discharge.,musculoskeletal:  no myalgias or arthralgias.,neurologic:  no chronic headaches, no seizures.  patient denies numbness, tingling or weakness.,psychiatric:  patient denies problems with mood disturbance.  no problems with anxiety.,endocrine:  no excessive urination or excessive thirst.,dermatologic:  patient denies any rashes or skin changes.",14
"operation: , insertion of a #8 shiley tracheostomy tube.,anesthesia: , general endotracheal anesthesia.,operative procedure in detail: , after obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch.  dissection was carried down using bovie electrocautery to the level of the trachea.  the 2nd tracheal ring was identified.  next, a #11-blade scalpel was used to make a trap door in the trachea.  the endotracheal tube was backed out.  a #8 shiley tracheostomy tube was inserted, and tidal co2 was confirmed when it was connected to the circuit.  we then secured it in place using 0 silk suture.  a sterile dressing was applied.  the patient tolerated the procedure well.",2
"description:,1.  normal cardiac chambers size.,2.  normal left ventricular size.,3.  normal lv systolic function.  ejection fraction estimated around 60%.,4.  aortic valve seen with good motion.,5.  mitral valve seen with good motion.,6.  tricuspid valve seen with good motion.,7.  no pericardial effusion or intracardiac masses.,doppler:,1.  trace mitral regurgitation.,2.  trace tricuspid regurgitation.,impression:,1.  normal lv systolic function.,2.  ejection fraction estimated around 60%.,",31
"procedures:,1.  right and left heart catheterization.,2.  coronary angiography.,3.  left ventriculography.,procedure in detail:,  after informed consent was obtained, the patient was taken to the cardiac catheterization laboratory.  patient was prepped and draped in sterile fashion.  via modified seldinger technique, the right femoral vein was punctured and a 6-french sheath was placed over a guide wire.  via modified seldinger technique, right femoral artery was punctured and a 6-french sheath was placed over a guide wire.  the diagnostic procedure was performed using the jl-4, jr-4, and a 6-french pigtail catheter along with a swan-ganz catheter.  the patient tolerated the procedure well and there were immediate complications were noted.  angio-seal was used at the end of the procedure to obtain hemostasis.,coronary arteries:,left main coronary artery:  the left main coronary artery is of moderate size vessel with bifurcation into the left descending coronary artery and circumflex coronary artery.  no significant stenotic lesions were identified in the left main coronary artery.,left anterior descending coronary artery:  the left descending artery is a moderate sized vessel, which gives rise to multiple diagonals and perforating branches.  no significant stenotic lesions were identified in the left anterior descending coronary artery system.,circumflex artery:  the circumflex artery is a moderate sized vessel.  the vessel is a stenotic lesion.  after the right coronary artery, the rca is a moderate size vessel with no focal stenotic lesions.,hemodynamic data: , capital wedge pressure was 22.  the aortic pressure was 52/24.  right ventricular pressure was 58/14.  ra pressure was 14.  the aortic pressure was 127/73.  left ventricular pressure was 127/15.  cardiac output of 9.2.,left ventriculogram: , the left ventriculogram was performed in the rao projection only.  in the rao projection, the left ventriculogram revealed dilated left ventricle with mild global hypokinesis and estimated ejection fraction of 45 to 50%.  severe mitral regurgitation was also noted.,impression:,1.  left ventricular dilatation with global hypokinesis and estimated ejection fraction of 45 to 50%.,2.  severe mitral regurgitation.,3.  no significant coronary artery disease identified in the left main coronary artery, left anterior descending coronary artery, circumflex coronary artery or the right coronary artery.,",2
"preoperative diagnosis:,  worrisome skin lesion, left hand.,postprocedure diagnosis:,  worrisome skin lesion, left hand.,procedure:,  the patient gave informed consent for his procedure.  after informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,local anesthetic medication was infiltrated around and into the area of interest.  there was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  a punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  the predominant portion of the biopsy was of the lesion itself.,lesion was removed.  attention was turned toward the area.  pressure was held and the area was hemostatic.,the skin and the area were closed with 5-0 nylon suture.  all counts were correct.  the procedure was closed.  a sterile dressing was applied.  there were no complications.  the patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,",36
"chief complaint:,  the patient is a 49-year-old caucasian male transported to the emergency room by his wife, complaining of shortness of breath.,history of present illness:, the patient is known by the nursing staff here to have a long history of chronic obstructive pulmonary disease and emphysema. he has made multiple visits in the past. today, the patient presents himself in severe respiratory distress. his wife states that since his recent admission of three weeks ago for treatment of pneumonia, he has not seemed to be able to recuperate, and has persistent complaints of shortness of breath.,today, his symptoms worsened and she brought him to the emergency room. to the best of her knowledge, there has been no fever. he has persistent chronic cough, as always. more complete history cannot be taken because of the patient’s acute respiratory decompensation.,past medical history:,  hypertension and emphysema.,medications:,  lotensin and some water pill as well as, presumably, an atrovent inhaler.,allergies:,  none are known.,habits:,  the patient is unable to cooperate with the history.,social history:,  the patient lives in the local area with his wife.,review of body systems:,  unable, secondary to the patient’s condition.,physical examination:,vital signs: temperature 96 degrees, axillary. pulse 128. respirations 48. blood pressure 156/100. initial oxygen saturations on room air are 80.,general: reveals a very anxious, haggard and exhausted-appearing male, tripoding, with labored breathing.,heent: head is normocephalic and atraumatic.,neck: the neck is supple without obvious jugular venous distention.,lungs: auscultation of the chest reveals very distant and faint breath sounds, bilaterally, without obvious rales.,heart: cardiac examination reveals sinus tachycardia, without pronounced murmur.,abdomen: soft to palpation.,extremities: without edema.,diagnostic data:,  white blood count 25.5, hemoglobin 14, hematocrit 42.4, 89 polys, 1 band, 4 lymphocytes. chemistry panel within normal limits, with the exception of sodium of 124, chloride 81, co2 44, bun 6, creatinine 0.7, glucose 182, albumin 3.3 and globulin 4.1. troponin is 0.11. urinalysis reveals yellow clear urine. specific gravity greater than 1.030 with 2+ ketones, 1+ blood and 3+ protein. no white cells and 0-2 red cells.,chest x-ray suboptimal in quality, but without obvious infiltrates, consolidation or pneumothorax.,critical care note:,  critical care one hour.,shortly after the patient’s initial assessment, the patient apparently began to complain of chest pain and appeared to the nurse to have mounting exhaustion and respiratory distress. although o2 had been placed, elevating his oxygen saturations to the mid to upper 90s, he continued to complain of symptoms, as noted above. he became progressively more rapidly obtunded. the patient did receive one gram of magnesium sulfate shortly after his arrival, and the bipap apparatus was being readied for his use. however, the patient, at this point, became unresponsive, unable to answer questions, and preparations were begun for intubation. the bipap apparatus was briefly placed while supplies and medications were assembled for intubation. it was noted that even with the bipap apparatus, in the duration of time which was required for transfer of oxygen tubing to the bipap mask, the patient’s o2 saturations rapidly dropped to the upper 60 range.,all preparations for intubation having been undertaken, succinylcholine was ordered, but was apparently unavailable in the department. as the patient was quite obtunded, and while the dacuronium was being sought, an initial trial of intubation was carried out using a straight blade and a cupped 7.9 endotracheal tube. however, the patient had enough residual muscle tension to make this impractical and further efforts were held pending administration of dacuronium 10 mg. after approximately two minutes, another attempt at intubation was successful. the cords were noted to be covered with purulent exudates at the time of intubation.,the endotracheal tube, having been placed atraumatically, the patient was initially then nebulated on 100% oxygen, and his o2 saturations rapidly rose to the 90-100% range.,chest x-ray demonstrated proper placement of the tube. the patient was given 1 mg of versed, with decrease of his pulse from the 140-180 range to the 120 range, with satisfactory maintenance of his blood pressure.,because of a complaint of chest pain, which i myself did not hear, during the patient’s initial triage elevation, a trial of tridil was begun. as the patient’s pressures held in the slightly elevated range, it was possible to push this to 30 mcg per minute. however, after administration of the dacuronium and versed, the patient’s blood pressure fell somewhat, and this medication was discontinued when the systolic pressure briefly reached 98.,because of concern regarding pneumonia or sepsis, the patient received one gram of rocephin intravenously shortly after the intubation. a nasogastric and foley were placed, and an arterial blood gas was drawn by respiratory therapy. dr. x was contacted at this point regarding further orders as the patient was transferred to the intensive care unit to be placed on the ventilator there. the doctor’s call was transferred to the intensive care unit so he could leave appropriate orders for the patient in addition to my initial orders, which included albuterol or atrovent q. 2h. and levaquin 500 mg iv, as well as solu-medrol.,critical care note terminates at this time.,emergency department course:,  see the critical care note.,medical decision making (differential diagnosis):,  this patient has an acute severe decompensation with respiratory failure. given the patient’s white count and recent history of pneumonia, the possibility of recurrence of pneumonia is certainly there. similarly, it would be difficult to rule out sepsis. myocardial infarction cannot be excluded.,coordination of care:,  dr. x was contacted from the emergency room and asked to assume the patient’s care in the intensive care unit.,final diagnosis:,  respiratory failure secondary to severe chronic obstructive pulmonary disease.,discharge instructions:, the patient is to be transferred to the intensive care unit for further management.",2
"chief complaint:,  this 26-year-old male presents today for a complete eye examination.,allergies:,  patient admits allergies to aspirin resulting in disorientation, gi upset.,medication history:,  patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by a. general practitioner md, adrenocot 0.5 mg tablet medication was prescribed by a. general practitioner md, vioxx 12.5 mg tablet (bid).,pmh: , past medical history is unremarkable.,past surgical history:,  patient admits past surgical history of (+) appendectomy in 1989.,social history:,  patient denies alcohol use.  patient denies illegal drug use.  patient denies std history.  patient denies tobacco use.,family history:,  unremarkable.,review of systems:,eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,constitutional symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,musculoskeletal: (-) joint or musculoskeletal symptoms.,eye exam:,  patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,pupils:  pupil exam reveals round and equally reactive to light and accommodation.,motility:  ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,visual fields:  confrontation vf exam reveals full to finger confrontation o.u.,iop:  iop method:  applanation tonometry od:  10 mmhg medications:  alphagan; 0.2% condition:  improving.,keratometry:,od:  k1 35.875k2 35.875,os:  k1 35.875k2 41.875,lids/orbit:  bilateral eyes reveal normal position without infection.  bilateral eyelids reveals white and quiet.,slit lamp:  corneal epithelium is intact with normal tear film and without stain.  stroma is clear and avascular.  corneal endothelium is smooth and of normal appearance.,anterior segment:  bilateral anterior chambers reveal no cells or flare with deep chamber.,lens:  bilateral lenses reveals transparent lens that is in normal position.,posterior segment:  posterior segment was dilated bilateral.  bilateral retinas reveal normal color, contour, and cupping.,retina:  bilateral retinas reveals flat with normal vasculature out to the far periphery.  bilateral retinas reveal normal reflex and color.,visual acuity:,visual acuity - uncorrected:  od:  20/10 os:  20/10 ou:  20/15.,refraction:,lenses - final:,od:  +0.50 +1.50 x 125 prism 1.75,os:  +6.00 +3.50 x 125 prism 4.00 base in fresnel,add:  od:  +1.00 os:  +1.00,ou:  far va 20/25,test results:,  no tests to report at this time.,impression:,  eye and vision exam normal.,plan:,  return to clinic in 12 month (s).,patient instructions:",4
"history of present illness:, the patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when i first saw him in the office on 01/11/06. he is now 77 years old. he is being seen on the seventh floor. the patient is in room 7607. the patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. the workup began with gi bleeding. he was seen in my office on 01/11/06 for preop evaluation due to leg edema. a nonocclusive dvt was diagnosed in the proximal left superficial femoral vein. both legs were edematous, and bilateral venous insufficiency was also present. an echocardiogram demonstrated an ejection fraction of 50%. the patient was admitted to the hospital and treated with a greenfield filter since anticoagulant was contraindicated. additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. the rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. there was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. the ejection fraction was considered low normal, since it was estimated 50 to 54%. the patient received blood while in the hospital due to anemia. the leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. the patient, who was diabetic, received consultation by dr. r. he was also a chronic hypertensive and was treated for that with ace inhibitors. the atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. as a matter of fact, they were discontinued. now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,allergies:, the patient has no known drug allergies.,his diabetes was suspected to be complicated with neuropathy due to tingling in both feet. he received his immunizations with flu in 2005 but did not receive pneumovax.,social history:, the patient is married. he had 1 child who died at the age of 26 months of unknown etiology. he quit smoking 6 years ago but dips (smokeless) tobacco.,family history:, mother had cancer, died at 70. father died of unknown cause, and brother died of unknown cause.,functional capacity:, the patient is wheelchair bound at the time of his initial hospitalization. he is currently walking in the corridor with assistance. nocturia twice to 3 times per night.,review of systems:,ophthalmologic: uses glasses.,ent: complains of occasional sinusitis.,cardiovascular: hypertension and atrial fibrillation.,respiratory: normal.,gi: colon bleeding. the patient believes he had ulcers.,genitourinary: normal.,musculoskeletal: complains of arthritis and gout.,integumentary: edema of ankles and joints.,neurological: tingling as per above. denies any psychiatric problems.,endocrine: diabetes, niddm.,hematologic and lymphatic: the patient does not use any aspirin or anticoagulants and is not of anemia.,laboratory:, current ekg demonstrates atrial fibrillation with incomplete left bundle branch block pattern. q waves are noticed in the inferior leads. nonprogression of the r-wave from v1 to v4 with small r-waves in v5 and v6 are suggestive of an old anterior and inferior infarcts. left ventilator hypertrophy and strain is suspected.,physical examination:,general: on exam, the patient is alert, oriented and cooperative. he is mildly pale. he is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,vital signs: blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. pulse oximetry is 100.,neck: without jvd, bruit, or thyromegaly. the neck is supple.,chest: symmetric. there is no heave or retraction.,heart: the heart sounds are irregular and no significant murmurs could be auscultated.,lungs: clear to auscultation.,abdomen: exam was deferred.,legs: without edema. pulses: dorsalis pedis pulse was palpated bilaterally.,medications:, current medications include enalapril, low dose enoxaparin, fentanyl patches. he is no longer on fluconazole. he is on a sliding scale as per dr. holden. he is on lansoprazole (prevacid), toradol, piperacillin/tazobactam, hydralazine p.r.n., zofran, dilaudid, benadryl, and lopressor p.r.n.,assessment and plan:, the patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. his cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. he has chronic atrial fibrillation. i do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. he is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. reason being is high likelihood for gi bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. at this point, i agree with the notion of hospice care. if his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, i would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.",4
"history of present illness:,  this is a 77-year-old male, who presents with gross hematuria that started this morning.  the patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too.  he is complaining of no other pain.  he denies any abdominal pain.  denies any bleeding anywhere else.  denies any bruising.  he had an episode similar to this a year ago where it began the same with hematuria.  he was discharged after a workup in the hospital, in the emergency room, with levaquin.  three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding.  his h and h was down in the 6 level.  he received blood transfusions.  he was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition.  family actually states that they were told that he was unlikely to live through that event, but he did.  since then, he has had no bleeding.  the patient has had no fever.  no cough.  no chest pain or shortness of breath.  no bleeding gums.  no blurred vision.  no headache.  no recent falls or trauma.  he has had no nausea or vomiting.  no diarrhea.  no blood in the stool or melena.  no leg or calf pain.  no joint pain.  no rashes.  no swollen glands.  he has no numbness, weakness or tingling to his extremities.  no acute anxiety or depression.,past medical history: , has prostate cancer.,medication: , he is receiving lupron injection by dr. y. the only other medication that he takes is tramadol.,social history: , he does not smoke or drink.,physical examination:,vital signs:  are all reviewed on triage.,general:  he is alert.  answers slowly with a speech impediment, but answers appropriately.,heent:  pupils equal, round, and reactive to light.  normal extraocular muscles.  nonicteric sclerae.  conjunctivae are not pale.  his oropharynx is clear.  his mucous membranes are moist.,heart:  regular rate and rhythm, with no murmurs.,lungs:  clear.,abdomen:  soft, nontender, nondistended.  normal bowel sounds.  no organomegaly or mass.,extremities:  no calf tenderness, erythema or warmth.  he has no bruises noted.,neurological:  cranial nerves ii through xii are intact.  he has 5/5 strength throughout.  ,gu:  normal.,laboratory data:  ,the patient did on urinalysis have few red blood cells.  his urine was also grossly red, although no blood clots or gross blood was noted.  it was more of a red fluid.  he had a mild decrease in h and h at 12.1 and 34.6.  his white count was normal at 7.2.  his pt was elevated at 15.9.  ptt elevated at 36.4.  inr is 1.4.  his comprehensive metabolic profile is normal except for bun of 19.,condition: , the patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with dr. x and he is admitted for orders.  also we will consult dr. y, see orders for further.",4
"delivery note:,  the patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  the patient presented to labor and delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  she was found to be positive for nitrazine pull and fern.  at that time, she was not actually contracting.  she was group b streptococcus positive, however, was 5 cm dilated.  the patient was started on group b streptococcus prophylaxis with ampicillin.  she received a total of three doses throughout her labor.  her pregnancy was complicated by scanty prenatal care.  she would frequently miss visits.  at 37 weeks, she claims that she had a suspicious bump on her left labia.  there was apparently no fluid or blistering of the lesion.  therefore, it was not cultured by the provider; however, the patient was sent for serum hsv antibody levels, which she tested positive for both hsv1 and hsv2.  i performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with dr. x, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  the patient requested an epidural anesthetic, which she received with very good relief.  she had iv pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  she delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  the baby delivered in the occiput anterior position.  the baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  the umbilical cord was doubly clamped and then cut.  the baby's apgars were 8 and 9.  the placenta was delivered spontaneously intact.  there was a three-vessel cord with normal insertion.  the fundus was massaged to firm and pitocin was administered through the iv per unit protocol.  the perineum was inspected and was found to be fully intact.  estimated blood loss was approximately 400 ml.  the patient's blood type is a+.  she is rubella immune and as previously mentioned, gbs positive and she received three doses of ampicillin.",22
"preoperative diagnosis: , left knee medial femoral condyle osteochondritis dissecans.,postoperative diagnosis: , left knee medial femoral condyle osteochondritis dissecans.,procedures:,  left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,anesthesia: , general.,tourniquet time:  ,thirty-seven minutes.,medications: , the patient also received 30 ml of 0.5% marcaine local anesthetic at the end of the case.,complications: , no intraoperative complications.,drains and specimens: , none.,intraoperative findings: , the patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  this loose body was then subsequently removed.  it measured 24 x 14 mm.  this was actually the ocd lesion seen on the mri that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,history and physical: , the patient is 13-year-old male with persistent left knee pain.  he was initially seen at sierra pacific orthopedic group where an mri demonstrated unstable ocd lesion of the left knee.  the patient presented here for a second opinion.  surgery was recommended grossly due to the instability of the fragment.  risks and benefits of surgery were discussed.  the risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  all questions were answered and parents agreed to the above plan.,description of procedure:  ,the patient was taken to the operating room and placed supine on the operating table.  general anesthesia was then administered.  the patient received ancef preoperatively.  a nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  the extremity was then prepped and draped in standard surgical fashion.  the standard portals were marked on the skin.  the extremity was wrapped in esmarch prior to inflation of tourniquet to 250 mmhg.  the portal incisions were then made by an #11 blade.  camera was inserted into the lateral joint line.  there was a noted large cartilage loose body in the suprapatellar pouch.  this was subsequently removed with extension of the anterolateral portal.  visualization of the rest of the knee revealed significant synovitis.  the patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  the remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  acl was also visualized to be intact in the intracondylar notch.,attention was then turned back to the large defect.  the loose cartilage was debrided using a shaver.  microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  all instruments were then removed.  the portals were closed using #4-0 monocryl.  a total of 30 ml of 0.5% marcaine was injected into the knee.  wounds were then cleaned and dried, and dressed in steri-strips, xeroform, 4 x 4s, and bias.  the patient was then placed in a knee immobilizer.  the patient tolerated the procedure well.  the tourniquet was released at 37 minutes.  he was taken to recovery in stable condition.,postoperative plan: , the loose cartilage fragment was given to the family.  the intraoperative findings were relayed with intraoperative photos.  there was a large deficit in the weightbearing portion of medial femoral condyle.  his prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at children's or possible cartilaginous transplant.  all questions were answered.  the patient will follow up in 10 days, may wet the wound in 5 days.",25
"history of present illness:,  this 66-year-old white male was seen in my office on month dd, yyyy.  patient was recently discharged from doctors hospital at parkway after he was treated for pneumonia.  patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  his exercise tolerance is about two to three yards for shortness of breath.  the patient stopped taking coumadin for reasons not very clear to him.  he was documented to have recent atrial fibrillation.  patient has longstanding history of ischemic heart disease, end-stage lv systolic dysfunction, and is status post icd implantation.  fasting blood sugar this morning is 130.,physical examination: , ,vital signs:  blood pressure is 120/60.  respirations 18 per minute.  heart rate 75-85 beats per minute, irregular.  weight 207 pounds.,heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good. ,neck:  supple.  jvp is flat.  carotid upstroke is good. ,lungs:  severe inspiratory and expiratory wheezing heard throughout the lung fields.  fine crepitations heard at the base of the lungs on both sides. ,cardiovascular:  pmi felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. first and second heart sounds are normal in character.  there is a ii/vi systolic murmur best heard at the apex.,abdomen:  soft.  there is no hepatosplenomegaly.,extremities:  patient has 1+ pedal edema.,medications: , ,1.  ambien 10 mg at bedtime p.r.n.,2.  coumadin 7.5 mg daily.,3.  diovan 320 mg daily.,4.  lantus insulin 50 units in the morning.,5.  lasix 80 mg daily.,6.  novolin r p.r.n.,7.  toprol xl 100 mg daily.,8.  flovent 100 mcg twice a day.,diagnoses:,1.  atherosclerotic coronary vascular disease with old myocardial infarction.,2.  moderate to severe lv systolic dysfunction.,3.  diabetes mellitus.,4.  diabetic nephropathy and renal failure.,5.  status post icd implantation.,6.  new onset of atrial fibrillation.,7.  chronic coumadin therapy.,plan:,1.  continue present therapy.,2.  patient will be seen again in my office in four weeks.",2
"preoperative diagnosis:,  left nasolabial fold scar deformity with effacement of alar crease.,postoperative diagnosis:,  left nasolabial fold scar deformity with effacement of alar crease.,procedures performed:,1.  left midface elevation with nasolabial fold elevation.,2.  left nasolabial fold z-plasty and right symmetrization midface elevation.,anesthesia: , general endotracheal intubation.,estimated blood loss: , less than 25 ml.,fluids: , crystalloid,cultures taken: , none.,patient's condition: , stable.,implants: , coapt endotine midface b 4.5 bioabsorbable implants, reference #cfd0200197, lot #01447 used on the right and used on the left side.,identification: , this patient is well known to the stanford plastic surgery service.  the patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  in particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  the patient was seen in consultation and felt to be a surgical candidate for improvement.  risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  the patient understood these risks and benefits and consented to the operation.,procedure in detail: , the patient was taken to or and placed supine on the operating table.  dose of antibiotics was given to the patient.  compression devices were placed on the lower extremities to prevent the knee embolic events.  the patient was turned to 180 degrees.  the ett tube was secured and the area was then prepped and draped in usual sterile fashion.  a head wrap was then placed on the position and we then began our local.  of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  local consisting a 50:50 mix of 0.25% marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  this was done bilaterally.  we then marked the nasolabial fold and began with the elevation of the left midface.,we began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  we continued down to the lateral orbital rim until we identified periosteum.  we then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  care was taken to preserve the infraorbital nerve and that was visualized after elevation.  we then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,we then used our endotine coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the coapt bioabsorbable screw.  after this was then carried out, we then clipped and cut as well as the end of the screw.  satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 monocryl.  several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  excess skin along the incision was then removed as well the skin from just lateral to the canthus.  care was taken to leave the orbicularis muscle down.  we then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 prolenes lateral to the canthus.,we then turned our attention to performing the z-plasty portion of the case.  a z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  this was carried out using a 15 blade down to subcutaneous tissue.  the flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  at this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  as such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  we carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,at this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our endotine midface implant into the desired area and then elevated slightly just for symmetry only.  this was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 pds and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 prolene lateral to the canthus.,at this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  satisfied with our procedures, we then placed cool compresses on to the eyes.,the patient was then extubated and brought to the pacu in stable condition.,dr. x was present and scrubbed for the entire case and actively participated during all key elements.  dr. y was available and participated in the portions of the case as well.",10
"cc: ,sensory loss.,hx: ,25y/o rhf began experiencing pruritus in the rue, above the elbow and in the right scapular region, on 10/23/92. in addition she had paresthesias in the proximal ble and toes of the right foot. her symptoms resolved the following day. on 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. the sensory loss gradually progressed rostrally to the mid chest. she felt unsteady on her feet and had difficulty ambulating. in addition she also began to experience pain in the right scapular region. she denied any heat or cold intolerance, fatigue, weight loss.,meds:, none.,pmh:, unremarkable.,fhx: ,gf with cad, otherwise unremarkable.,shx:, married, unemployed. 2 children. patient was born and raised in iowa. denied any h/o tobacco/etoh/illicit drug use.,exam:,  bp121/66 hr77 rr14 36.5c,ms: a&o to person, place and time. speech normal with logical lucid thought process.,cn: mild optic disk pallor os. no rapd. eom full and smooth. no ino. the rest of the cn exam was unremarkable.,motor: full strength throughout all extremities except for 5/4+ hip extensors. normal muscle tone and bulk.,sensory: decreased pp/lt below t4-5 on the left side down to the feet. decreased pp/lt/vib in ble (left worse than right). allodynic in rue.,coord: intact fnf, hks and ram, bilaterally.,station: no pronator drift. romberg's test not documented.,gait: unsteady wide-based. able to tt and hw. poor tw.,reflexes: 3/3 bue. hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ achilles with 3-4 beat nonsustained clonus. plantar responses were extensor on the right and flexor on the left.,gen. exam: unremarkable.,course:, cbc, gs, pt, ptt, esr, ft4, tsh, ana, vit b12, folate, vdrl and urinalysis were normal. mri t-spine, 10/27/92, was unremarkable. mri brain, 10/28/92, revealed multiple areas of abnormally increased signal on t2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. the appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, lumbar puncture revealed the following csf results: rbc 1, wbc 9 (8 lymphocytes, 1 histiocyte), glucose 55mg/dl, protein 46mg/dl (normal 15-45), csf igg 7.5mg/dl (normal 0.0-6.2), csf igg index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. beta-2 microglobulin was unremarkable. an abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. visual and brainstem auditory evoked potentials were normal. htlv-1 titers were negative. csf cultures and cytology were negative. she was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,she returned on 11/7/92 as her symptoms of rue dysesthesia, lower extremity paresthesia and weakness, all worsened. on 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. she also began having difficulty emptying her bladder. her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. she was oriented to place and time of day, but not to season, day of the week and she did not know who she was. she had a leftward gaze preference and right lower facial weakness. her rle was spastic with sustained ankle clonus. there was dysesthetic sensory perception in the rue. jaw jerk and glabellar sign were present.,mri brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. the right peritrigonal region is more prominent than on prior study. the left centrum semiovale lesion has less enhancement than previously. multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. the peritrigonal lesions on both sides have increased in size since the 10/92 mri. the findings were felt more consistent with demyelinating disease and less likely glioma. post-viral encephalitis, rapidly progressive demyelinating disease and tumor were in the differential diagnosis. lumbar puncture, 11/8/92, revealed: rbc 2, wbc 12 (12 lymphocytes), glucose 57, protein 51 (elevated), cytology and cultures were negative. hiv 1 titer was negative. urine drug screen, negative. a stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. she was treated with decadron 6mg iv qhours and cytoxan 0.75gm/m2 (1.25gm). on 12/3/92, she has a focal motor seizure with rhythmic jerking of the lue, loss of consciousness and rightward eye deviation. eeg revealed diffuse slowing with frequent right-sided sharp discharges. she was placed on dilantin. she became depressed.",31
"cc:, horizontal diplopia.,hx: , this 67 y/orhm first began experiencing horizontal binocular diplopia 25 years prior to presentation in the neurology clinic. the diplopia began acutely and continued intermittently for one year. during this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. he received no treatment and the diplopia spontaneously resolved. he did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. the diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. it resolves when he covers one eye. it is worse when looking at distant objects and objects off to either side of midline. there are no other symptoms associated with the diplopia.,pmh:, 1)4vessel cabg and pacemaker placement, 4/84. 2)hypercholesterolemia. 3)bipolar affective d/o.,fhx: ,htn, colon ca, and a daughter with unknown type of ""dystonia."",shx:, denied tobacco/etoh/illicit drug use.,ros:, no recent weight loss/fever/chills/night sweats/cp/sob. he occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,meds: ,lithium 300mg bid, accupril 20mg bid, cellufresh ophthalmologic tears, asa 325mg qd.,exam:, bp216/108 hr72 rr14 wt81.6kg t36.6c,ms: unremarkable.,cn: horizontal binocular diplopia on lateral gaze in both directions. no other cn deficits noted.,motor: 5/5 full strength throughout with normal muscle bulk and tone.,sensory: unremarkable.,coord: mild ""ataxia"" of ram (left > right),station: no pronator drift or romberg sign,gait: unremarkable. reflexes: 2/2 symmetric throughout. plantars (bilateral dorsiflexion),studies/course:, gen screen: unremarkable. brain ct revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. this shows no mass effect, but demonstrates mild contrast enhancement. there are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. the midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). metastatic lesions could show calcification but one would expect to see some degree of edema. the long standing clinical history suggest the former (i.e. hemangioma).,no surgical or neuroradiologic intervention was done and the patient was simply followed. he was lost to follow-up in 1993.",31
"chief complaint:, sinus problems.,sinusitis history:, the problem began 2 weeks ago and is constant. symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. additional symptoms include snoring, nasal burning and teeth pain. the symptoms are characterized as moderate to severe. symptoms are worse in the evening and morning.,review of systems:,ros general: general health is good.,ros ent: as noted in history of present illness listed above.,ros respiratory: patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ros gastrointestinal: patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ros respiratory: complaints include coughing.,ros neurological: patient complains of headaches. all other systems are negative.,past surgical history:, gallbladder 7/82. hernia 5/79,past medical history:, negative.,past social history:, marital status: married. denies the use of alcohol. patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. there are no animals inside the home.,family medical history:, family history of allergies and hypertension.,current medications:, claritin. dilantin.,previous medications utilized:, rhinocort nasal spray.,exam:,exam ear: auricles/external auditory canals reveal no significant abnormalities bilaterally. tms intact with no middle ear effusion and are mobile to insufflation.,exam nose: intranasal exam reveals moderate congestion and purulent mucus.,exam oropharynx: examination of the teeth/alveolar ridges reveals missing molar (s). examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. the palatine tonsils are 2+ and cryptic.,exam neck: palpation of anterior neck reveals no tenderness. examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,exam facial: there is bilateral maxillary sinus tenderness to palpation.,x-ray / lab findings:, water's view x-ray reveals bilateral maxillary mucosal thickening.,impression:, acute maxillary sinusitis (461.0).  snoring (786.09).,medication:, augmentin. 875 mg bid. mucofen 800 mg bid.,plan:,",10
"exam:,  ct examination of the abdomen and pelvis with intravenous contrast.,indications:,  abdominal pain.,technique:  ,ct examination of the abdomen and pelvis was performed after 100 ml of intravenous isovue-300 contrast administration.  oral contrast was not administered.  there was no comparison of studies.,findings,ct pelvis:,within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  there is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  there is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  several smaller fibroids were also suspected.,the ovaries are unremarkable in appearance.  there is no free pelvic fluid or adenopathy.,ct abdomen:,the appendix has normal appearance in the right lower quadrant.  there are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  the small and large bowels are otherwise unremarkable.  the stomach is grossly unremarkable.  there is no abdominal or retroperitoneal adenopathy.  there are no adrenal masses.  the kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  the spleen contains several small calcified granulomas, but no evidence of masses.  it is normal in size.  the lung bases are clear bilaterally.  the osseous structures are unremarkable other than mild facet degenerative changes at l4-l5 and l5-s1.,impression:,1.  hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  multiple uterine fibroids.,3.  prominent endometrium.,4.  followup pelvic ultrasound is recommended.",22
"preoperative diagnoses: , cervical disk protrusions at c5-c6 and c6-c7, cervical radiculopathy, and cervical pain.,postoperative diagnoses:,  cervical disk protrusions at c5-c6 and c6-c7, cervical radiculopathy, and cervical pain.,procedures:,  c5-c6 and c6-c7 anterior cervical discectomy (two levels) c5-c6 and c6-c7 allograft fusions.  a c5-c7 anterior cervical plate fixation (sofamor danek titanium window plate) intraoperative fluoroscopy used and intraoperative microscopy used.  intraoperative ssep and emg monitoring used.,anesthesia: , general endotracheal.,complications:,  none.,indication for the procedure: , this lady presented with history of cervical pain associated with cervical radiculopathy with cervical and left arm pain, numbness, weakness, with mri showing significant disk protrusions with the associate complexes at c5-c6 and c6-c7 with associated cervical radiculopathy.  after failure of conservative treatment, this patient elected to undergo surgery.,description of procedure:  ,the patient was brought to the or and after adequate general endotracheal anesthesia, she was placed supine on the or table with the head of the bed about 10 degrees.  a shoulder roll was placed and the head supported on a donut support.  the cervical region was prepped and draped in the standard fashion.  a transverse cervical incision was made from the midline, which was lateral to the medial edge of the sternocleidomastoid two fingerbreadths above the right clavicle.  in a transverse fashion, the incision was taken down through the skin and subcutaneous tissue and through the platysmata and a subplatysmal dissection done.  then, the dissection continued medial to the sternocleidomastoid muscle and then medial to the carotid artery to the prevertebral fascia, which was gently dissected and released superiorly and inferiorly.  spinal needles were placed into the displaced c5-c6 and c6-c7 to confirm these disk levels using lateral fluoroscopy.  following this, monopolar coagulation was used to dissect the medial edge of the longus colli muscles off the adjacent vertebrae between c5-c7 and then the trimline retractors were placed to retract the longus colli muscles laterally and blunt retractors were placed superiorly and inferiorly.  a #15 scalpel was used to do a discectomy at c5-c6 from endplate-to-endplate and uncovertebral joint.  on the uncovertebral joint, a pituitary rongeur was used to empty out any disk material ____________ to further remove the disk material down to the posterior aspect.  this was done under the microscope.  a high-speed drill under the microscope was used to drill down the endplates to the posterior aspect of the annulus.  a blunt trocar was passed underneath the posterior longitudinal ligament and it was gently released using the #15 scalpel and then kerrison punches 1-mm and then 2-mm were used to decompress further disk calcified material at the c5-c6 level.  this was done bilaterally to allow good decompression of the thecal sac and adjacent neuroforamen.  then, at the c6-c7 level, in a similar fashion, #15 blade was used to do a discectomy from uncovertebral joint to uncovertebral joint and from endplate-to-endplate using a #15 scalpel to enter the disk space and then the curette was then used to remove the disk calcified material in the endplate, and then high-speed drill under the microscope was used to drill down the disk space down to the posterior aspect of the annulus where a blunt trocar was passed underneath the posterior longitudinal ligament which was gently released.  then using the kerrison punches, we used 1-mm and 2-mm, to remove disk calcified material, which was extending more posteriorly to the left and the right.  this was gently removed and decompressed to allow good decompression of the thecal sac and adjacent nerve roots.  with this done, the wound was irrigated.  hemostasis was ensured with bipolar coagulation.  vertebral body distraction pins were then placed to the vertebral body of c5 and c7 for vertebral distraction and then a 6-mm allograft performed grafts were taken and packed in either aspect with demineralized bone matrix and this was tapped in flush with the vertebral bodies above and below c5-c6 and c6-c7 discectomy sites.  then, the vertebral body distraction pins were gently removed to allow for graft seating and compression and then the anterior cervical plate (danek windows titanium plates) was then taken and sized and placed.  a temporary pin was initially used to align the plate and then keeping the position and then two screw holes were drilled in the vertebral body of c5, two in the vertebral body of c6, and two in the vertebral body of c7.  the holes were then drilled and after this self-tapping screws were placed into the vertebral body of c5, c6, and c7 across the plate to allow the plate to fit and stay flush with the vertebral body between c5, c6, and c7.  with this done, operative fluoroscopy was used to check good alignment of the graft, screw, and plate, and then the wound was irrigated.  hemostasis was ensured with bipolar coagulation and then the locking screws were tightened down.  a #10 round jackson-pratt drain was placed into the prevertebral space and brought out from a separate stab wound skin incision site.  then, the platysma was approximated using 2-0 vicryl inverted interrupted stitches and the skin closed with 4-0 vicryl running subcuticular stitch.  steri-strips and sterile dressings were applied.  the patient remained hemodynamically stable throughout the procedure.  throughout the procedure, the microscope had been used for the disk decompression and high-speed drilling.  in addition, intraoperative ssep, emg monitoring, and motor-evoked potentials remained stable throughout the procedure.  the patient remained stable throughout the procedure.",36
"preoperative diagnosis: , lipodystrophy of the abdomen and thighs.,postoperative diagnosis:,  lipodystrophy of the abdomen and thighs.,operation: , suction-assisted lipectomy.,anesthesia:,  general.,findings and procedure:,  with the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  after this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  through these small incisions, a cannula was used to infiltrate lactated ringers with 1000 cc was infiltrated initially into the abdomen.  a 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  attention was then directed to the thighs both inner and outer.  a total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  after this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  the patient tolerated the procedure very well.  all of this aspirate was mostly fat with little fluid and very little blood.  wounds were cleaned and steri-stripped and dressing of abd pads and ***** was then applied.  the patient tolerated the procedure very well and was sent to the recovery room in good condition.",1
"preoperative diagnosis:  ,esophageal rupture.,postoperative diagnosis:,  esophageal rupture.,operation performed,1.  left thoracotomy with drainage of pleural fluid collection.,2.  esophageal exploration and repair of esophageal perforation.,3.  diagnostic laparoscopy and gastrostomy.,4.  radiographic gastrostomy tube study with gastric contrast, interpretation.,anesthesia: , general anesthesia.,indications of the procedure: , the patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  he has esophageal rupture on ct scan and comes now for a thoracotomy and gastrostomy.,details of the procedure: , after an extensive informed consent discussion process, the patient was brought to the operating room.  he was placed in a supine position on the operating table.  after induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  left chest was prepped and draped in a usual sterile fashion.  after administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  the left lung was deflated and the pleural cavity entered.  the finochietto retractor was used to help provide exposure.  the sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,immediately encountered was left pleural fluid including some purulent fluid.  cultures of this were sampled and sent for microbiology analysis.  the left pleural space was then copiously irrigated.  a careful expiration demonstrated that the rupture appeared to be sealed.  there was crepitus within the mediastinal cavity.  the mediastinum was opened and explored and the esophagus was explored.  the tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  it was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  the area was copiously irrigated, this provided nice coverage and repair.  after final irrigation and inspection, two chest tubes were placed including a #36 french right angled tube at the diaphragm and a posterior straight #36 french.  these were secured at the left axillary line region at the skin level with #0-silk.,the intercostal sutures were used to close the chest wall with a #2 vicryl sutures.  muscle layers were closed with running #1 vicryl sutures.  the wound was irrigated and the skin was closed with skin staples.,the patient was then turned and placed in a supine position.  a laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  a veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  the laparoscope was introduced.  a single additional left-sided separator trocar was introduced.  it was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  the stomach however did have some air insufflation and we were able to place our t-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  the skin incision was made and the gastric lumen was then accessed with the seldinger technique.  guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 french gastrostomy was then passed into the stomach lumen and the balloon was inflated.  we confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  the t-fasteners were all crimped and secured into position.  as was in the plan, the gastrostomy was secured to the skin and into the tube.  sterile dressing was applied.  aspiration demonstrated gastric content.,gastrostomy tube study, with interpretation.  radiographic gastrostomy tube study with gastric contrast, with",36
"indication:,  prostate cancer.,technique:,  3.5 hours following the intravenous administration of 26.5 mci of technetium 99m mdp, the skeleton was imaged in the anterior and posterior projections.,findings:,  there is a focus of abnormal increased tracer activity overlying the right parietal region of the skull.  the uptake in the remainder of the skeleton is within normal limits.  the kidneys image normally.  there is increased activity in the urinary bladder suggesting possible urinary retention.,conclusion:,1.  focus of abnormal increased tracer activity overlying the right parietal region of the skull.  ct scanning of magnetic resonance imaging of the skull and brain could be done for further assessment if it is clinically indicated.,2.  there is probably some degree of urinary retention.,",37
"cc:, horizontal diplopia.,hx: , this 67 y/orhm first began experiencing horizontal binocular diplopia 25 years prior to presentation in the neurology clinic. the diplopia began acutely and continued intermittently for one year. during this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. he received no treatment and the diplopia spontaneously resolved. he did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. the diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. it resolves when he covers one eye. it is worse when looking at distant objects and objects off to either side of midline. there are no other symptoms associated with the diplopia.,pmh:, 1)4vessel cabg and pacemaker placement, 4/84. 2)hypercholesterolemia. 3)bipolar affective d/o.,fhx: ,htn, colon ca, and a daughter with unknown type of ""dystonia."",shx:, denied tobacco/etoh/illicit drug use.,ros:, no recent weight loss/fever/chills/night sweats/cp/sob. he occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,meds: ,lithium 300mg bid, accupril 20mg bid, cellufresh ophthalmologic tears, asa 325mg qd.,exam:, bp216/108 hr72 rr14 wt81.6kg t36.6c,ms: unremarkable.,cn: horizontal binocular diplopia on lateral gaze in both directions. no other cn deficits noted.,motor: 5/5 full strength throughout with normal muscle bulk and tone.,sensory: unremarkable.,coord: mild ""ataxia"" of ram (left > right),station: no pronator drift or romberg sign,gait: unremarkable. reflexes: 2/2 symmetric throughout. plantars (bilateral dorsiflexion),studies/course:, gen screen: unremarkable. brain ct revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. this shows no mass effect, but demonstrates mild contrast enhancement. there are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. the midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). metastatic lesions could show calcification but one would expect to see some degree of edema. the long standing clinical history suggest the former (i.e. hemangioma).,no surgical or neuroradiologic intervention was done and the patient was simply followed. he was lost to follow-up in 1993.",20
"operation performed:,  full mouth dental rehabilitation in the operative room under general anesthesia.,preoperative diagnosis: , severe dental caries.,postoperative diagnoses:,1.  severe dental caries.,2.  non-restorable teeth.,complications:,  none.,estimated blood loss: , minimal.,duration of surgery: , 43 minutes.,brief history:  ,the patient was first seen by me on 04/26/2007.  she had a history of open heart surgery at 11 months' of age.  she presented with severe anterior caries with most likely dental extractions needed.  due to her young age, i felt that she would be best served in the safety of the hospital operating room.  after consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at children's hospital.,operative preparation:  ,this child was brought to hospital day surgery and is accompanied by her mother.  there i met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  after all their questions and concerns were addressed, i gave the informed consent to proceed with the treatment.  the patient's history and physical examination was reviewed.  once she was cleared by anesthesia and the child was taken back to the operating room.,operative procedure:  ,the patient was placed on the surgical table in the usual supine position with all extremities protected.  anesthesia was induced by mask.  the patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  the head was wrapped and the eyes were taped shut for protection.  an angiocatheter was placed in the left hand and an iv was started.  the head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  a moist continuous throat pack was placed beyond the tonsillar pillars.  plastic lip and cheek retractors were then placed.  preoperative clinical photographs were taken.  two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  after the radiographs were taken, the lead shield was removed.  prophylaxis was then performed using prophy cup and fluoridated prophy paste.  the teeth were then rinsed well and the patient's oral cavity was suctioned clean.  clinical and radiographic examinations followed and areas of decay were noted.  during the restorative phase, these areas of decay were entered into and removed.  entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  non-restorable primary teeth would be extracted.,upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  the original treatment plan was verified with the actual treatment provided.  postoperative clinical photographs were then taken.  the continuous gauze throat pack was removed with continuous suction with visualization.  topical fluoride was then placed on the teeth.,at the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,findings:  ,this young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  all primary teeth were present.  dental caries were present on the following teeth:  tooth d, e, f, and g caries on all surfaces; teeth j, lingual caries.  the remainder of her teeth and soft tissues were within normal limits.  the following restorations and procedures were performed:  tooth d, e, f, and g were extracted and four sutures were placed one at each extraction site and tooth j lingual amalgam.,conclusion:  ,the mother was informed of the completion of the procedure.  she was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  they will contact to my office in the event of immediate postoperative complications.  after full recovery, she was discharged from the recovery room in the care of her mother.",6
"preoperative diagnosis: , blighted ovum, severe cramping.,postoperative diagnosis:,  blighted ovum, severe cramping.,operation performed: , vacuum d&c.,drains: , none.,anesthesia: , general.,history: , this 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  due to the severe cramping, a decision to undergo vacuum d&c was made.  at the time of the procedure, moderate amount of tissue was obtained.,procedure:  ,the patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  the patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  a weighted vaginal speculum was placed in the posterior vaginal vault.  anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  plastic curette was placed into the uterine cavity and suction was applied at 60 mmhg to remove the tissue.  this was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  methargen 0.2 mg was given im and pitocin 40 units and a 1000 was also started at the time of the procedure.  once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  the patient was repositioned to supine position and taken to recovery room in stable condition.",22
"ct abdomen without contrast and ct pelvis without contrast,reason for exam: , evaluate for retroperitoneal hematoma, the patient has been following, is currently on coumadin.,ct abdomen: , there is no evidence for a retroperitoneal hematoma.,the liver, spleen, adrenal glands, and pancreas are unremarkable.  within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  a 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  no calcifications are noted.  the kidneys are small bilaterally.,ct pelvis: , evaluation of the bladder is limited due to the presence of a foley catheter, the bladder is nondistended.  the large and small bowels are normal in course and caliber.  there is no obstruction.,bibasilar pleural effusions are noted.,impression:,1. no evidence for retroperitoneal bleed.,2. there are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. the kidneys are small in size bilaterally.,4. bibasilar pleural effusions.",19
"procedure: , circumcision.,pre-procedure diagnosis: , normal male phallus.,post-procedure diagnosis: , normal male phallus.,anesthesia:  ,1% lidocaine without epinephrine.,indications: , the risks and benefits of the procedure were discussed with the parents.  the risks are infection, hemorrhage, and meatal stenosis.  the benefits are ease of care and cleanliness and fewer urinary tract infections.  the parents understand this and have signed a permit.,findings: , the infant is without evidence of hypospadias or chordee prior to the procedure.,technique:  ,the infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,the infant was prepped then with betadine and draped with a sterile towel in the usual manner.  clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  dorsal hemostasis was established and a dorsal slit was made.  the foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  the infant was fitted with a xx-cm plastibell.  the foreskin was retracted around the plastibell and circumferential hemostasis was established.  the excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.",27
"presentation: , a 16-year-old male presents to the emergency department (ed) with rectal bleeding and pain on defecation.,history:,  a 16-year-old african american male presents to the ed with a chief complaint of rectal bleeding and pain on defecation.  the patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  the following day he noted increasing pain and first noted blood on the surface of his stool.  the pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  the patient denies any previous history of rectal bleeding or pain.  he also denies any previous sexually transmitted diseases (stds) and states that he was screened for hiv infection eight months ago and was negative.  the patient does state that he has not felt well for the past week.  he states that he had felt ""feverish"" on several occasions but has not taken his temperature.  he has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  he thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,the patient states that he has been sexually active since age 13.  he admits to eight previous partners and states that he ""usually"" uses a condom.  on further questioning, the patient states that of his eight partners, three were female and five were male.  his most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  he states that he has been tested for stds in the past but states that he only gave urine and blood for the testing.  he is unaware of the hiv status of his partner but assumes that the partner is uninfected because he looks healthy.  the patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  as the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  he is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  he is accessing care in the ed unaccompanied by an adult.,physical exam: , thin but non-toxic young man with clear discomfort.,pulse = 105,rr = 23,bp = 120/62,heent:  several areas of white plaque-like material on the buccal mucosa.,neck:  multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,lungs:  clear to auscultation.,cardiac:  quiet precordium.,nl s1/s2 with a ii/vi systolic murmur. ,abdomen:  soft without hepatosplenomegaly.,gu:  tanner v male with no external penile lesions.,lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,multiple 1-2 cm inguinal nodes.,rectal:  extremely painful digital exam.,+ gross blood and mucous.,laboratory evaluation:,hbg = 12.  5 gm/dl,hct = 32%,wbc = 3.9 thou/µl,platelets = 120,000 thou/µl,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,alt = 82 u/l,ast= 90 u/l,erythrocyte sedimentation rate = 90,electrolytes = normal,gram stain of anal swab:  numerous wbcs,differential diagnosis: , this patient is presenting with acute rectal pain with bleeding and anal discharge.  the patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  the following are in the differential diagnosis:  acute proctitis and  proctocolitis.,acute hiv seroconversion: , this subject is sexually active and reports inconsistent condom use.  gastrointestinal symptoms have recently been reported commonly in patients with a history of hiv seroconversion.  the rectal symptoms of bleeding and pain are not common with hiv, and an alternative diagnosis would be required.,perirectal abscess: , a patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent std.  the patient could experience more systemic symptoms with fever and malaise, as found with this patient.  however, the physical examination did not reveal the typical localized area of pain and edema.,diagnosis:  ,the subject had rectal cultures obtained, which were positive for neisseria gonorrhoeae.  an hiv elisa was positive, as was the rna pcr.,discussion: , this patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  first, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  although not ideal in many circumstances, testing for hiv infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when hiv counseling and testing were not performed.  second, this young man has had both male and female sexual partners.  as young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  third, screening for stds must take into account sexual behaviors.  although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  if a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out stds.  fourth, this young man had both localized and systemic symptoms.  as his anal symptoms were most suggestive of a current std, performing an hiv test should be part of the standard evaluation.  in addition, as acute infection is on the differential diagnosis, pcr testing should also be considered.  the care provided to this young man included the following.  he was treated presumptively for proctitis with both im ceftriaxone as well as oral doxycycline to treat n gonorrhoeae and c trachomatis.  ceftriaxone was chosen due to the recent reports of resistant n gonorrhoeae.  at the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific hiv program.  the case manager linked this young man directly to care after providing brief counseling and support.  the case manager maintained contact with the young man until his first clinical visit four days later.  over the subsequent three months, the young man had two sets of laboratory testing to stage his hiv infection.,set #1 cd4 t-lymphocyte count = 225 cells/mm3, 15% ,quantitative rna pcr = 75,000 copies/ml",13
"reason for visit:  ,the patient is a 76-year-old man referred for neurological consultation by dr. x.  the patient is companied to clinic today by his wife and daughter.  he provides a small portion of his history; however, his family provides virtually all of it.,history of present illness: , he has trouble with walking and balance, with bladder control, and with thinking and memory.  when i asked him to provide me detail, he could not tell me much more than the fact that he has trouble with his walking and that he has trouble with his bladder.  he is vaguely aware that he has trouble with his memory.,according to his family, he has had difficulty with his gait for at least three or four years.  at first, they thought it was weakness and because of he was on the ground (for example, gardening) he was not able to get up by himself.  they did try stopping the statin that he was taking at that time, but because there was no improvement over two weeks, they resumed the statin.  as time progressed, he developed more and more difficulty.  he started to shuffle.  he started using a cane about two and a half years ago and has used a walker with wheels in the front since july of 2006.  at this point, he frequently if not always has trouble getting in or out of the seat.  he frequently tends to lean backwards or sideways when sitting.  he frequently if not always has trouble getting in or out a car, always shuffles or scuffs his feet, always has trouble turning or changing direction, always has trouble with uneven surfaces or curbs, and always has to hold on to someone or something when walking.  he has not fallen in the last month.  he did fall earlier, but there seemed to be fewer opportunities for him to fall.  his family has recently purchased a lightweight wheelchair to use if he is traveling long distances.  he has no stairs in his home, however, his family indicates that he would not be able to take stairs.  his handwriting has become smaller and shakier.,in regard to the bladder, he states, ""i wet the bed.""  in talking with his family, it seems as if he has no warning that he needs to empty his bladder.  he was diagnosed with a small bladder tumor in 2005.  this was treated by dr. y.  dr. x does not think that the bladder tumor has anything to do with the patient's urinary incontinence.  the patient has worn a pad or undergarment for at least one to one and a half years.  his wife states that they go through two or three of them per day.  he has been placed on medications; however, they have not helped.,he has no headaches or sensation of head fullness.,in regard to the thinking and memory, at first he seemed forgetful and had trouble with dates.  now he seems less spontaneous and his family states he seems to have trouble expressing himself.  his wife took over his medications about two years ago.  she stopped his driving about three years ago.  she discovered that his license had been expired for about a year and she was concerned enough at that time that she told him he could drive no more.  apparently, he did not object.  at this point, he frequently has trouble with memory, orientation, and everyday problems solving at home.  he needs coaching for his daily activities such as reminders to brush his teeth, put on his clothes, and so forth.  he is a retired office machine repairman.  he is currently up and active about 12 hours a day and sleeping or lying down about 12 hours per day.,he has not had pt or ot and has not been treated with medications for parkinson's disease or alzheimer's disease.  he has been treated for the bladder.  he has not had lumbar puncture.,past medical history and review of all 14 systems from the form they completed for this visit that i reviewed with them is negative with the exception that he has had hypertension since 1985, hypercholesterolemia since 1997, and diabetes since 1998.  the bladder tumor was discovered in 2005 and was treated noninvasively.  he has lost weight from about 200 pounds to 180 pounds over the last two or three years.  he had a period of depression in 1999 and was on prozac for a while, but this was then stopped.  he used to drink a significant amount of alcohol.  this was problematic enough that his wife was concerned.  she states he stopped when she retired and she was at home all day.,social history:  ,he quit smoking in 1968.  his current weight is 183 pounds.  his tallest height is 5 feet 10 inches.,family history:  ,his grandfather had arthritis.  his father had parkinson's disease.  his mother had heart disease and a sister has diabetes.,he does not have a living will and indicates he would wish his wife to make decisions for him if he could not make them for himself.,review of hydrocephalus risk factors: , none.,allergies: , none.,medications: , metformin 500 mg three times a day, lipitor 10 mg per day, lisinopril 20 mg per day, metoprolol 50 mg per day, uroxatral 10 mg per day, detrol la 4 mg per day, and aspirin 81 mg per day.,physical exam: , on examination today, this is a pleasant 76-year-old man who is guided back from the clinic waiting area walking with his walker.  he is well developed, well nourished, and kempt.,vital signs:  his weight is 180 pounds.,head:  the head is normocephalic and atraumatic.  the head circumference is 59 cm, which is the ,75-90th percentile for an adult man whose height is 178 cm.,spine:  the spine is straight and not tender.  i can easily palpate the spinous processes.  there is no scoliosis.,skin:  no neurocutaneous stigmata.,cardiovascular examination:  no carotid or vertebral bruits.,mental status:  assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  the mini-mental state exam score was 17/30.  he did not know the year, season, or day of the week nor did he know the building or specialty or the floor.  there was a tendency for perseveration during the evaluation.  he could not copy the diagram of intersecting pentagons.,cranial nerve exam:  no evidence of papilledema.  the pupillary light reflex is intact as are extraocular movements without nystagmus, facial expression and sensation, hearing, head turning, tongue, and palate movement.,motor exam:  normal bulk and strength, but the tone is marked by significant paratonia.  there is no atrophy, fasciculations, or drift.  there is tremulousness of the outstretched hands.,sensory exam:  is difficult to interpret.  either he does not understand the test or he is mostly guessing.,cerebellar exam:  is intact for finger-to-nose, heel-to-knee, and rapid alternating movement tests.  there is no dysarthria.,reflexes:  trace in the arms, 2+ at the knees, and 0 at the ankles.  it is not certain whether there is a babinski sign or simply withdrawal.,gait:  assessed using the tinetti assessment tool that shows a balance score of 7-10/16 and a gait score of 2-5/12 for a total score of 9-15/28, which is significantly impaired.,review of x-rays: , i personally reviewed the mri scan of the brain from december 11, 2007 at advanced radiology.  it shows the ventricles are enlarged with a frontal horn span of 5.0 cm.  the 3rd ventricle contour is flat.  the span is enlarged at 12 mm.  the sylvian aqueduct is patent.  there is a pulsation artifact.  the corpus callosum is effaced.  there are extensive t2 signal abnormalities that are confluent in the corona radiata.  there are also scattered t2 abnormalities in the basal ganglia.  there is a suggestion of hippocampal atrophy.  there is also a suggestion of vermian atrophy.,assessment: , the patient has a clinical syndrome that raises the question of idiopathic normal pressure hydrocephalus.  his examination today is notable for moderate-to-severe dementia and moderate-to-severe gait impairment.  his mri scan raises the question of hydrocephalus, however, is also consistent with cerebral small vessel disease.,problems/diagnoses:,1.  possible idiopathic normal pressure hydrocephalus (331.5).,2.  probable cerebral small-vessel disease (290.40 & 438).,3.  gait impairment (781.2).,4.  urinary urgency and incontinence (788.33).,5.  dementia.,6.  hypertension.,7.  hypercholesterolemia.",4
"cc:, seizures.,hx: ,the patient was initially evaluated at uihc at 7 years of age. he had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. they occurred quite infrequently and he was able to resume activity immediately following the episodes. the spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. in addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,birth hx:, 32 weeks gestation to a g4 mother and weighed 4#11oz. he was placed in an incubator for 3 weeks. he was jaundiced, but there was no report that he required treatment.,pmh: ,single febrile convulsion lasting ""3 hours"" at age 2 years.,meds: ,none.,exam:, appears healthy and in no acute distress. unremarkable general and neurologic exam.,impression: psychomotor seizures.,studies: skull x-rays were unremarkable.,eeg showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. this record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",course:, the patient was initially treated with phenobarbital; then dilantin was added (early 1970's); then depakene was added ( early 1980's) due to poor seizure control. an eeg on 8/22/66 showed ""left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). in addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" he underwent his first hct scan in sioux city in 1981, and this revealed an right temporal arachnoid cyst. the patient had behavioral problems throughout elementary/junior high/high school. he underwent several neurosurgical evaluations at uihc and mayo clinic and was told that surgery was unwarranted. he was placed on numerous antiepileptic medication combinations including tegretol, dilantin, phenobarbital, depakote, acetazolamide, and mysoline. despite this he averaged 2-3 spells a month. he was last seen, 6/19/95, and was taking dilantin and tegretol. his typical spells were described as sudden in onset and without aura. he frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. he usually has rapid recovery and can return to work in 20 minutes. he works at a turkey packing plant. serial hct scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.",20
"diagnosis: , t1 n3 m0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed june, 2006; status post 2 cycles  carboplatin/5-fu given as adjuvant therapy, completed september, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,performance status:,  0.,interval history: , in the interim since his last visit he has done quite well.  he is working.  he did have an episode of upper respiratory infection and fever at the end of april which got better with antibiotics.  overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  he has no complaints other than mild xerostomia and treatment related hearing loss.,physical examination:,vital signs:  height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,heent:  extraocular muscles intact.  sclerae not icteric.  oral cavity free of exudate or ulceration.  dry mouth noted.,lymph:  no palpable adenopathy in cervical, supraclavicular or axillary areas.,lungs:  clear.,cardiac:  rhythm regular.,abdomen:  soft, nondistended.  neither liver, spleen, nor other masses palpable.,lower extremities:  without edema.,neurologic:  awake, alert, ambulatory, oriented, cognitively intact.,i reviewed the ct images and report of the study done on may 1.  this showed no evidence of metabolically active malignancy.,most recent laboratory studies were performed last september and the tsh was normal.  i have asked him to repeat the tsh at the one year anniversary.,he is on no current medications.,in summary, this 57-year-old man presented with t1 n3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  he has made a good recovery.  we will continue to follow thyroid function and i have asked him to obtain a tsh at the one year anniversary in september and cbc in follow up.  we will see him in six months' time with a pet-ct.,he returns to the general care and direction of dr. abc.",4
"subjective:  ,school reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  he appears confused and depressed at times.  mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  he will attend social skills program in the summer.  abcd indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  there is lessening of tremoring in both hands since discontinuation of zoloft.  he is now currently taking abilify at 7.5 mg.,objective: , he came in less perseverative questioning, asked appropriate question about whether i talked to abcd or not, greeted me with japanese word to say hello, seemed less.,i also note that his tremors were less from the last time.,assessment: , 299.8 asperger disorder, 300.03 obsessive compulsive disorder.,plan:,  decrease abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  i am introducing slow luvox 25 mg tablet one-half a.m. for ocd symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,i also will call abcd regarding the referral to psychologists for functional behavioral analysis.  parents will call me in two weeks.  i will see him for medication review in four weeks.  mother signed informed consent.  i reviewed side effects to observe including behavioral activation.,abilify has been helpful in decreasing high emotional arousal.  combination of medication and behavioral intervention is recommended.",30
"history of injury and present complaints: , the patient is a 59-year-old gentleman.  he is complaining chiefly of persistent lower back pain.  he states the pain is of a rather constant nature.  he describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  he states he has difficulty with prolonged standing or sitting.  he can only stand for about 5-10 minutes, then he has to sit down.  he can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  he has difficulty with bending and stooping maneuvers.  he describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  he gets numbness along the lateral aspect of the foot itself.  he also describes chronic pain complaints with associated tension in the back of his neck.  he states the pain is of a constant nature in his neck.  he states he gets pain that radiates into the right shoulder girdle area and the right forearm.  he describes some numbness along the lateral aspect of the right forearm.  he states he has trouble trying to use his arm at or above shoulder height.  he has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  he describes pain at the anterior aspect of his shoulder, in particular.  he denies any headache complaints.  he is relating his above complaints to two industrial injuries that he sustained while employed with frito lay company as a truck driver or delivery person.  he relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  he lost his footing and fell.  he reached out to grab the hand railing.  he fell backwards on his back and his right shoulder.  he had immediate onset of shoulder pain, neck pain, and low back pain.  he had pain into his right leg.  he initially came under the care of dr. h, an occupational physician in modesto.  initially, he did not obtain any mris or x-rays.  he did undergo some physical therapy and received some medications.  dr. h referred him to dr. q, a chiropractor for three visits, which the patient was not certain was very helpful.  the patient advises he then changed treating physicians to dr. n, d.c., whom he had seen previously for some back pain complaints back in 1990.  he felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  he continues with rather persistent pain in his right shoulder.  he underwent an mri of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  the patient was referred to dr. p, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  he felt that the patient might require a cortisone injection or possibly a surgical intervention.  the patient also underwent an mri of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  there is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at c5-6 and c6-7 levels.  the patient was also seen by dr. p, a neurologist for a neurology consult.  it is unclear to me as to whether or not dr. p had performed an emg or nerve conduction studies of his upper or lower extremities.  the patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  he returned back to regular duty.  dr. n declared him permanent and stationary on 04/04/1995.  the patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for frito lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  at that time, he returned to see dr. n for chiropractic care, who is his primary treating physician.  dr. n took him off work again.  he was off work again for approximately another six months, during which time, he was seen by dr. m, m.d., a neurosurgeon.  he had a new mri of his lumbar spine performed.  the mri was performed on 05/20/1997.  it revealed l4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  the radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  dr. m saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the l4-5 level following a more recent mri exam of 05/20/1997, from previous mri exam of 1996 which revealed a rather prominent right-sided l4-5 disc herniation.  dr. m felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that emg studies of the right upper extremity should be obtained and he may require a repeat mri of the cervical spine, if the study was positive.  the patient did undergo some nerve conduction studies of his lower extremities with dr. k, m.d., which suggested a possible abnormal emg with evidence of possible l5 radiculopathy, both right and left.  unfortunately, i had no medical reports from dr. p suggesting that he may have performed nerve conduction studies or emgs of the upper and lower extremities.  the patient did see dr. r for a neurosurgical consult.  dr. r evaluated both his neck and lower back pain complaints on several occasions.  dr. r suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  the patient underwent these injections with dr. k.  the patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  it is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  dr. r on 12/15/2004 suggested that the patient had an mri of the cervical spine revealing a right-sided c5-6 herniated nucleus pulposus which would explain his c-6 distribution numbness.  the patient also was noted to have a c4-5 with rather severe degenerative disc disease.  he felt the patient might be a candidate for a two-level acdf at c4-5 and c5-6.  dr. r in another report of 08/11/2004 suggested that the patient's mri of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  he had an l4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the l6 level as well, with lumbarization of s1.  he felt that his examination suggested a possible right s1 radiculopathy with discogenic back pain.  he would suggest right-sided s1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a dynesys or a fusion or some major spine surgery to help resolve his situation., ,the patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  he continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  he is currently taking no medications to manage his pain complaints.  he states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  he returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on ttd status by dr. n, his primary treating physician.  the patient states he has not been back to work since.  he has since applied for social security disability and now is receiving social security disability benefits.  the patient states he has tried some myox therapy with dr. h on 10 sessions, which he found somewhat helpful.  overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for frito lay.,",16
"subjective:,  this 3-year-old male is brought by his mother with concerns about his eating.  he has become a very particular eater, and not eating very much in general.  however, her primary concern was he was vomiting sometimes after particular foods.  they had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  after this occurred several times, they stopped giving him carrots.  last week, he ate some celery and the same thing happened.  they had not given him any of that since.  he eats other foods without any apparent pain or vomiting.  bowel movements are normal.  he does have a history of reactive airway disease, intermittently.  he is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,current medications:,  he is on no medications.,allergies: , he has no known medicine allergies.,objective:,vital signs:  weight:  31.5 pounds, which is an increase of 2.5 pounds since may.  temperature is 97.1.  he certainly appears in no distress.  he is quite interested in looking at his books.,neck:  supple without adenopathy.,lungs:  clear.,cardiac:  regular rate and rhythm without murmurs.,abdomen:  soft without organomegaly, masses, or tenderness.,assessment:,  report of vomiting and abdominal pain after eating raw carrots and celery.  etiology of this is unknown.,plan:,  i talked with mother about this.  certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  at this time, they will simply avoid those foods.  in the future, they may certainly try those again and see how he tolerates those.  i did encourage a wide variety of fruits and vegetables in his diet as a general principle.  if worsening symptoms, she is welcome to contact me again for reevaluation.",14
"exam: , transvaginal ultrasound.,history: , pelvic pain.,findings: , the right ovary measures 1.6 x 3.4 x 2.0 cm.  there are several simple-appearing probable follicular cysts. there is no abnormal flow to suggest torsion on the right.  left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  this could represent a large hemorrhagic cyst versus abscess.  there is no evidence for left ovarian torsion.  there is a small amount of fluid in the cul-de-sac likely physiologic.,the uterus measures 7.7 x 5.0 cm.  the endometrial echo is normal at 6 mm.,impression:,1.  no evidence for torsion.,2.  large, complex cystic left ovarian mass as described.  this could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.",31
"procedure performed:,  cataract extraction with lens implantation, right eye.,description of procedure: , the patient was brought to the operating room.  the patient was identified and the correct operative site was also identified.  a retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adequate anesthetic was assured, and the eye was massaged to reduce risk of bleeding.  the patient was prepped and draped in the usual fashion.  a lid speculum was applied.,a groove incision at the 12 o'clock position was made with a 5700 blade.  this was beveled anteriorly in a lamellar fashion using the crescent knife.  then the anterior chamber was entered with a slit knife.  the chamber was deepened with viscoat.  then a paracentesis at the 3 o'clock position was created using a super sharp blade.  a cystitome was used to nick the anterior capsule and then the capsulotomy was completed with capsulorrhexis forceps.  hydrodissection was employed using bss on a blunt 27-gauge needle.,the phaco tip was then introduced into the eye, and the eye was divided into 4 grooves.  then a second instrument was used, a sinskey hook, to crack these grooves, and the individual quadrants were brought into the central zone and phacoemulsified.  i/a proceeded without difficulty using the irrigation/aspiration cannula.  the capsule was felt to be clear and intact.  the capsular bag was then expanded with provisc.,the internal corneal wound was increased using the slit knife.  the lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded.  a corneal light shield was then used as the wound was sutured with a figure-of-eight 10-0 nylon suture.  then the viscoat was removed using i/a, and the suture drawn up and tied.,the 0.2 ml of gentamicin was injected subconjunctivally.  maxitrol ointment was instilled into the conjunctival sac.  the eye was covered with a double patch and shield, and the patient was discharged.",24
"history of present illness: , goes back to yesterday, the patient went out for dinner with her boyfriend.  the patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night.  she was found down on the floor this morning, soiled her bowel movements.  paramedics were called and the patient was brought to the emergency room.  the patient was in the emergency room noted to be in respiratory failure, was intubated.  the patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure.  the patient was started on vasopressors.  the patient was started on iv fluids as well as iv antibiotic.  the ct of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation.  a general surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure.  the patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis.  the patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,past medical history:  ,significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,past surgical history:  ,significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,social history: , she lives with her boyfriend.  the patient has a history of heavy tobacco and alcohol abuse for many years.,family history: , not available at this current time.,review of systems: , as mentioned above.,physical examination:,general:  she is intubated, obtunded, gangrenous ears with gangrenous fingertips.,vital signs:  blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,heent:  examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light.  no oropharyngeal lesions noted.,neck:  supple.  no jvd, distention or carotid bruit.  no lymphadenopathy.,lungs:  bilateral crackles and bruits.,abdomen:  distended, unable to evaluate if this is tender.  no hepatosplenomegaly.  bowel sounds are very hyperactive.,lower extremities:  show no edema.  distal pulses are decreased.,overall neurological:  examination cannot be assessed.,laboratory data: , the database was available at this point of time.  wbc count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration.  pt inr is prolonged at 1.7 and aptt is prolonged at 60.  sodium was 143, bun of 36, and creatinine of 2.5.  the patient's blood gas shows ph of 7.05, po2 of 99.6, and pco2 of 99.6.  bicarb is 16.5.,assessment and evaluation:,1.  septicemia with septic shock.,2.  metabolic acidosis.,3.  respiratory failure.,4.  anuria.,5.  acute renal failure.,the patient has no blood pressure at this point in time.  the patient is on iv fluids.  the patient is on vasopressors due to ventilator support, bronchodilators as well as iv antibiotics.  her overall prognosis is extremely poor.  this was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from iowa.  the patient will be maintained on these supports at this point in time, but prognosis is poor.",4
"preoperative diagnosis: , ruptured globe with uveal prolapse ox.,postoperative diagnosis:,  ruptured globe with uveal prolapse ox.,procedure:  ,repair of ruptured globe with repositing of uveal tissue ox.,anesthesia: ,general,specimens:,  none.,complications:,  none.,indications: , this is a xx-year-old (wo)man with a ruptured globe of the xxx eye.,procedure: ,  the risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. informed consent was obtained. the patient received iv antibiotics including ancef and levaeuin prior to surgery. the patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. a wire lid speculum was carefully placed to provide exposure. a two-armed 7 mm scleral laceration was seen in the supranasal quadrant. the laceration involved the sclera and the limbus in this area. there was a small amount of iris tissue prolapsed in the wound. the westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. a cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. the anterior chamber remained formed and the iris tissue easily resumed its normal position. the pupil appeared round. an 8-0 nylon suture was used to close the scleral portion of the laceration. three sutures were placed using the 8-0 nylon suture. then 9-0 nylon suture was used to close the limbal portion of the wound. after the wound appeared closed, a superblade was used to create a paracentesis at approximately 2 o'clock. bss was injected through the paracentesis to fill the anterior chamber. the wound was checked and found to be watertight. no leaks were observed. an 8-0 vicryl suture was used to reposition the conjunctiva and close the wound. three 8-0 vicryl sutures were placed in the conjunctiva. all scleral sutures were completely covered. the anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. subconjunctival injections of ancef and dexamethasone were given at the end of the case as well as tobradex ointment. the lid speculum was carefully removed. the drapes were carefully removed. sterile saline was used to clean around the xxx eye as well as the rest of the face. the area was carefully dried and an eye patch and shield were taped over the xxx eye. the patient was awakened from general anesthesia without difficulty. (s)he was taken to the recovery area in good condition. there were no complications.",36
"preoperative diagnosis:,  aortoiliac occlusive disease.,postoperative diagnosis:, aortoiliac occlusive disease.,procedure performed:, aortobifemoral bypass.,operative findings: , the patient was taken to the operating room.  the abdominal contents were within normal limits.  the aorta was of normal size and consistency consistent with arteriosclerosis.  a 16x8 mm gore-tex graft was placed without difficulty.  the femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,procedure: , the patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with betadine solution.  a longitudinal incision was made after a betadine-coated drape was placed over the incisional area.  longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  hemostasis was obtained with electrocautery.  the common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  hemostasis was obtained with electrocautery.  the abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  mild adhesions were lysed.  the omentum was freed.  the small and large intestine were run with no evidence of abnormalities.  the liver and gallbladder were within normal limits.  no abnormalities were noted.  at this point, the bookwalter retractor was placed.  ng tube was placed in the stomach and placed on suction.  the intestines were gently packed intraabdominally and laterally.  the rest of the peritoneum was then opened.  the aorta was cleared, both proximally and distally.  the left iliac was completely occluded.  the right iliac was to be cleansed.  at this point, 5000 units of aqueous heparin was administered to allow take effect.  the aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  a single lumbar was ligated with #3-0 prolene.  the inferior mesenteric artery was occluded intraluminally and required no suture closure.  care was taken to preserve collaterals.  the aorta was measured, and a 16 mm gore-tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 prolene in a running fashion.  last stitch was tied.  hemostasis was excellent.  the clamp was gradually removed and additional prolene was placed in the right posterolateral aspect to obtain better hemostasis.  at this point, strong pulses were present within the graft.  the limbs were vented and irrigated.  using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  the grafts were then brought through these, care being taken to avoid twisting of the graft.  at this point, the right iliac was then ligated using #0 vicryl and the clamp was removed.  hemostasis was excellent.  the right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with potts scissors.  the graft was _____ and anastomosed to the artery using #5-0 prolene in a continuous fashion with a stitch _______ running fashion.  prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  flow was initially restored proximally then distally with good results.  attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  the artery was opened, extended with a potts scissors and anastomosis was performed with #5-0 prolene again with satisfactory hemostasis.  the last stitch was tied.  strong pulses were present within the artery and graft itself.  at this point, 25 mg of protamine was administered.  the wounds were irrigated with antibiotic solution.  the groins were repacked.  attention was then returned to the abdomen.  the retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  the shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  the intraabdominal contents were then allowed to resume their normal position.  there was no evidence of ischemia to the large or small bowel.  at this point, the omentum and stomach were repositioned.  the abdominal wall was closed in a running single layer fashion using #1 pds.  the skin was closed with skin staples.  the groins were again irrigated, closed with #3-0 vicryl and #4-0 undyed vicryl and steri-strips.  the patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  sponges and instrument counts were correct.  estimated blood loss 900 cc.",36
"findings:,normal foramen magnum.,normal brainstem-cervical cord junction. there is no tonsillar ectopia. normal clivus and craniovertebral junction. normal anterior atlantoaxial articulation.,c2-3: there is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. normal central canal and intervertebral neural foramina.,c3-4: there is disc desiccation with a posterior central disc herniation of the protrusion type. the small posterior central disc protrusion measures 3 x 6mm (ap x transverse) in size and is producing ventral thecal sac flattening. csf remains present surrounding the cord. the residual ap diameter of the central canal measures 9mm. there is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,c4-5: there is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. the disc osteophyte complex measures approximately 5mm in its ap dimension. there is minimal posterior annular bulging measuring approximately 2mm. the ap diameter of the central canal has been narrowed to 9mm. csf remains present surrounding the cord. there is probable radicular impingement upon the exiting right c5 nerve root.,c5-6: there is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. the disc protrusion measures approximately 3 x 8mm (ap x transverse) in size. there is ventral thecal sac flattening with effacement of the circumferential csf cleft. the residual ap diameter of the central canal has been narrowed to 7mm. findings indicate a loss of the functional reserve of the central canal but there is no cord edema. there is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,c6-7: there is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. there is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting c7 nerve roots.,c7-t1, t1-2: there is disc desiccation with no disc displacement. normal central canal and intervertebral neural foramina.,t3-4: there is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and csf surrounding the cord.,impression:,multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,c3-4 posterior central disc herniation of the protrusion type but no cord impingement.,c4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right c5 nerve root.,c5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential csf cleft indicating a limited functional reserve of the central canal.,c6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting c7 nerve roots.,t3-4 degenerative disc disease with posterior annular bulging.",3
"chief complaint:,  a 5-month-old boy with cough.,history of present illness:,  a 5-month-old boy brought by his parents because of 2 days of cough.  mother took him when cough started 2 days go to clinic where they told the mother he has viral infection and gave him tylenol, but yesterday at night cough got worse and he also started having fever.  mother did not measure it.,review of systems:,  no vomiting.  no diarrhea.  he had runny nose started with the cough two days ago.  no skin rash.  no cyanosis.  pulling on his right ear.  feeding, he is bottle-fed 2 ounces every 2 hours.  mother states he urinates like 5 to 6 times a day, stools 1 time a day.  he is still feeding good to mom.,immunizations: , he received first set of shot and due for the second set on 01/17/2008.,birth history:,  he was premature at 33 weeks born at hospital kept in nicu for 2 weeks for feeding problem as the mother said.  mother had good prenatal care at 4 weeks for more than 12 visits.  no complications during pregnancy.  rupture of membranes happened two days before the labor.  mother received the antibiotics, but she is not sure, if she received steroids also or not.,family history: , no history of asthma or lung disease.,social history: , lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in corrales.  they have animals, but outside the house and father smokes outside house.  no sick contacts as the mother said.,past medical history:,  no hospitalizations.,allergies: , no known drug allergies.,medications: , no medications.,history of 2 previous ear infection, last one was in last november treated with ear drops, because there was pus coming from the right ear as the mother said.,physical examination:  ,vital signs:  temperature 100.1, heart rate 184, respiratory rate 48.  weight 7 kg.,general:  in no acute distress.,head:  normocephalic and atraumatic.  open, soft, and flat anterior fontanelle.,neck:  supple.,nose:  dry secretions.,ear:  right ear full of yellowish material most probably pus and necrotic tissue.  tympanic membrane bilaterally visualized.,mouth:  no pharyngitis.  no ulcers.  moist mucous membranes.,chest:  bilateral audible breath sound.  no wheezes.  no palpitation.,heart:  regular rate and rhythm with no murmur.,abdomen:  soft, nontender, and nondistended.,genitourinary:  tanner i male with descended testes.,extremities:  capillary refill less than 2 seconds.,labs:,  white blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000.  crp 6, segments 41, and bands 41.  rsv positive.  chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region.  subsegmental atelectasis in the right upper lobe and left lung base.,assessment:,  a 5-month-old male with 2 days of cough and 1 day of fever.  chest x-ray shows bronchiolitis with atelectasis, and rsv antigen is positive.,diagnoses: , respiratory syncytial virus bronchiolitis with right otitis externa.,plan: , plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,",27
"subjective:,  grandfather brings the patient in today because of headaches, mostly in her face.  she is feeling pressure there with a lot of sniffles.  last night, she complained of sore throat and a loose cough.  over the last three days, she has had a rash on her face, back and arms.  a lot of fifth disease at school.  she says it itches and they have been doing some benadryl for this.  she has not had any wheezing lately and is not taking any ongoing medications for her asthma.,past medical history:,  asthma and allergies.,family history:  ,sister is dizzy but no other acute illnesses.,objective:,general:  the patient is an 11-year-old female.  alert and cooperative.  no acute distress.,neck:  supple without adenopathy.,heent:  ear canals clear.  tms, bilaterally, gray in color and good light reflex.  oropharynx is pink and moist.  no erythema or exudates.  she has postnasal discharge.  nares are swollen and red.  purulent discharge in the posterior turbinates.  both maxillary sinuses are tender.  she has some mild tenderness in the left frontal sinus.  eyes are puffy and she has dark circles.,chest:  respirations are regular and nonlabored.,lungs:  clear to auscultation throughout.,heart:  regular rhythm without murmur.,skin:  warm, dry and pink.  moist mucous membranes.  red, lacey rash from the wrists to the elbows, both sides.  it is very faint on the lower back and she has reddened cheeks, as well.,assessment:,  fifth disease with sinusitis.,plan:,  omnicef 300 mg daily for 10 days.  may use some zyrtec for the itching.  samples are given.",33
"problem:  ,rectal bleeding, positive celiac sprue panel.,history:  ,the patient is a 19-year-old irish-greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits.  she noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody.  she has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved.  she actually has none of these symptoms since starting her gluten-free diet.  she has noted intermittent rectal bleeding with constipation, on the toilet tissue.  she feels remarkably better after starting a gluten-free diet.,allergies: , no known drug allergies.,operations: , she is status post a tonsillectomy as well as ear tubes.,illnesses: , questionable kidney stone.,medications: , none.,habits: , no tobacco.  no ethanol.,social history: , she lives by herself.  she currently works in a dental office.,family history: , notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well.  she has two sisters and one brother.  one sister interestingly has inflammatory arthritis.,review of systems:  ,notable for fever, fatigue, blurred vision, rash and itching; her gi symptoms that were discussed in the hpi are actually resolved in that she started the gluten-free diet.  she also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination.  please see symptoms summary sheet dated april 18, 2005.,physical examination:  , general:  she is a well-developed pleasant 19 female.  she has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds.  she has anicteric sclerae.  pink conjunctivae.  perrla.  ent:  mmm.  neck:  supple.  lungs: clear to auscultation.",4
"exam: , cta chest pulmonary angio.,reason for exam: , evaluate for pulmonary embolism.,technique: , postcontrast ct chest pulmonary embolism protocol, 100 ml of isovue-300 contrast is utilized.,findings: , there are no filling defects in the main or main right or left pulmonary arteries.  no central embolism.  the proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below.  there is no evidence of a central embolism.,as seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35.  just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm.  given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed.  however, there is considerable change in the appearance of the lung fields.  there are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis.  there are also extensive right lung consolidations, all new or increased significantly from the prior examination.  again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded.  there is no pneumothorax in the interval.,on the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here.  there is aortic root and arch and descending thoracic aortic calcification.  there are scattered regions of soft plaque intermixed with this.  the heart is not enlarged.  the left axilla is intact in regards to adenopathy.  the inferior thyroid appears unremarkable.,limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound.  spleen, adrenal glands, and upper kidneys appear unremarkable.  visualized portions of the pancreas are unremarkable.,there is extensive rib destruction in the region of the chest wall mass.  there are changes suggesting prior trauma to the right clavicle.,impression:,1.  again demonstrated is a large right chest wall mass.,2.  no central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3.  new bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4.  see above regarding other findings.",2
"indications:  ,chest pain, hypertension, type ii diabetes mellitus.,procedure done:,  dobutamine myoview stress test.,stress ecg results:,  the patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  the resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, qs pattern in leads v1 and v2, and diffuse nonspecific t wave abnormality.  the heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  the blood pressure increased from 130/80 to 160/70.  a maximum of 1 mm j-junctional depression was seen with fast up sloping st segments during dobutamine infusion.  no ischemic st segment changes were seen during dobutamine infusion or during the recovery process.,myocardial perfusion imaging:,  resting myocardial perfusion spect imaging was carried out with 10.9 mci of tc-99m myoview.  dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mci of tc-99m myoview.  the lung heart ratio is 0.36.  myocardial perfusion images were normal both at rest and with stress.  gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,conclusions:,1.  stress test is negative for dobutamine-induced myocardial ischemia.,2.  normal left ventricular size, regional wall motion, and ejection fraction.",2
"cc:, headache,hx: ,this 16 y/o rhf was in good health, until 11:00pm, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. her parents described her as holding her head between her hands. she had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. the vomiting continued every 30 minutes and she developed neck stiffness. at 2:00am on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. her mother noted she appeared weak on the left side. shortly after this she experienced fecal and urinary incontinence. she was taken to a local er and transferred to uihc.,pmh/fhx/shx:, completely unremarkable fhx. has boyfriend and is sexually active.,denied drug/etoh/tobacco use.,meds:, oral contraceptive pill qd.,exam:, bp152/82 hr74 rr16 t36.9c,ms: somnolent and difficult to keep awake. prefer to lie on right side because of neck pain/stiffness. answers appropriately though when questioned.,cn: no papilledema noted. pupils 4/4 decreasing to 2/2. eom intact. face: ?left facial weakness. the rest of the cn exam was unremarkable.,motor: upper extremities: 5/3 with left pronator drift. lower extremities: 5/4 with lle weakness evident throughout.,coordination: left sided weakness evident.,station: left pronator drift.,gait: left hemiparesis.,reflexes: 2/2 throughout. no clonus. plantars were flexor bilaterally.,gen exam: unremarkable.,course: ,the patient underwent emergent ct brain. this revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. she then underwent a 4-vessel cerebral angiogram. this study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. this suggested straight sinus thromboses. mri brain was then done; this was unremarkable and did not show sign of central venous thrombosis. cbc/blood cx/esr/pt/ptt/gs/csf cx/ana were negative.,lumbar puncture on 12/1/87 revealed an opening pressure of 55cmh20, rbc18550, wbc25, 18neutrophils, 7lymphocytes, protein25mg/dl, glucose47mg/dl, cx negative.,the patient was assumed to have had a sah secondary to central venous thrombosis due to oral contraceptive use. she recovered well, but returned to neurology at age 32 for episodic blurred vision and lightheadedness. eeg was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.",20
"chief complaint:, palpitations.,chest pain / unspecified angina pectoris history:, the patient relates the recent worsening of chronic chest discomfort. the quality of the pain is sharp and the problem started 2 years ago. pain radiates to the back and condition is best described as severe. patient denies syncope. beyond baseline at present time. past work up has included 24 hour holter monitoring and echocardiography. holter showed pvcs.,palpitations history:, palpitations - frequent, 2 x per week. no caffeine, no etoh. + stress. no change with inderal.,valvular disease history:, patient has documented mitral valve prolapse on echocardiography in 1992.,past medical history:, no significant past medical problems. mitral valve prolapse.,family medical history:, cad.,ob-gyn history:, the patients last child birth was 1997. para 3. gravida 3.,social history:, denies using caffeinated beverages, alcohol or the use of any tobacco products.,allergies:, no known drug allergies/intolerances.,current medications:, inderal 20 prn.,review of systems:, generally healthy. the patient is a good historian.,ros head and eyes: denies vision changes, light sensitivity, blurred vision, or double vision.,ros ear, nose and throat: the patient denies any ear, nose or throat symptoms.,ros respiratory: patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ros gastrointestinal: patient denies any gastrointestinal symptoms, such as anorexia, weight loss, dysphagia, nausea, vomiting, abdominal pain, abdominal distention, altered bowel movements, diarrhea, constipation, rectal bleeding, hematochezia.,ros genitourinary: patient denies any genito-urinary complaints, such as hematuria, dysuria, frequency, urgency, hesitancy, nocturia, incontinence.,ros gynecological: denies any gynecological complaints, such as vaginal bleeding, discharge, pain, etc.,ros musculoskeletal: the patient denies any past or present problems related to the musculoskeletal system.,ros extremities: the patient denies any extremities complaints.,ros cardiovascular: as per hpi.,examination:,exam abdomen/flank: the abdomen is soft without tenderness or palpable masses. no guarding, rigidity or rebound tenderness. the liver and spleen are not palpable. bowel sounds are active and normal.,exam extremities: lower extremities are normal in color, touch and temperature. no ischemic changes are noted.,range of motion is normal. there is no cyanosis, clubbing or edema.,general: healthy appearing, well developed,. the patient is in no acute distress.,exam skin negative to inspection or palpation. there are no obvious lesions or new rashes noted. non-diaphoretic.,exam ears canals are clear. throat is not injected. tonsils are not swollen or injected.,exam neck: there is no thyromegaly, carotid bruits, lymphadenopathy, or jvd. neck is supple.,exam respiratory: normal breath sounds are heard bilaterally. there is no wheezing. there is no use of accessory muscles.,exam cardiovascular: regular heart rate and rhythm, normal s1 and s2 without murmur, gallops or rubs.,impression / diagnosis:, mitral valve prolapse. palpitations.,tests ordered:, cardiac tests: echocardiogram.,medication prescribed:, ,cardizem 30-60 qid prn.",2
"history of present illness: , the patient is a 68-year-old woman whom i have been following, who has had angina.  in any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when i spoke to her.  i advised her to call 911, which she did.  while waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  by the time she presented here, she is currently pain-free and is feeling well.,past cardiac history: , the patient has been having arm pain for several months.  she underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  i had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  however, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  on 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid lad lesion, circumflex normal, and rca totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  the decision was made to transfer  her as she may be having collateral insufficiency from the lad stenosis to the rca vessel.  she underwent that with drug-eluting stents on 08/16/08, with i believe three or four total placed, and was discharged on 08/17/08.  she had some left arm discomfort on 08/18/08, but this was mild.  yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  this is her usual angina.  she is being admitted with unstable angina post stent.,past medical history: , longstanding hypertension, cad as above, hyperlipidemia, and overactive bladder.,medications:,1.  detrol la 2 mg once a day.,2.  prilosec for gerd 20 mg once a day.,3.  glucosamine 500/400 mg once a day for arthritis.,4.  multivitamin p.o. daily.,5.  nitroglycerin sublingual as available to her.,6.  toprol-xl 25 mg once a day which i started although she had been bradycardic, but she seems to be tolerating.,7.  aspirin 325 mg once a day.,8.  plavix 75 mg once a day.,9.  diovan 160 mg once a day.,10.  claritin 10 mg once a day for allergic rhinitis.,11.  norvasc 5 mg once a day.,12.  lipitor 5 mg once a day.,13.  evista 60 mg once a day.,allergies: , allergies to medications are none.  she denies any shrimp or sea food allergy.,family history: , her father died of an mi in his 50s and a brother had his first mi and bypass surgery at 54.,social history:  ,she does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  she is divorced and lives alone and is a retired laboratory technician from cornell diagnostic laboratory.,review of systems:,  she denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  no morning headaches or fatigue.  no psychiatric diagnosis.  no psoriasis, no lupus.  remainder of the review of systems is negative x14 systems except as described above.,physical examination:,general:  she is a pleasant elderly woman, currently in no acute distress.,vital signs:  height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and o2 saturation 100%,heent:  cranium is normocephalic and atraumatic.  she has moist mucosal membranes.,neck:  veins are not distended.  there are no carotid bruits.,lungs:  clear to auscultation and percussion without wheezes.,heart:  s1 and s2, regular rate.  no significant murmurs, rubs or gallops.  pmi nondisplaced.,abdomen:  soft and nondistended.  bowel sounds present.,extremities:  without significant clubbing, cyanosis or edema.  pulses grossly intact.  bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for pci and there is no evidence of hematoma or bruit and intact distal pulses.,laboratory data: , ekg reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  bun 16 and creatinine 0.9.  glucose 110.  magnesium 2.5.  alt 107 and ast 65 and these were normal on 08/15/08.  inr is 0.89, ptt 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,impression and plan:  ,the patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  in any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, i am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  we will continue her beta-blocker and i cannot increase the dose because she is bradycardic already.  aspirin, plavix, valsartan, lipitor, and norvasc.  i am going to add imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out mi, although there is a little suspicion.  i suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  my concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal lv function.  she will continue the glucosamine for her arthritis, claritin for allergies, and detrol la for urinary incontinence.,total patient care time in the emergency department 75 minutes.  all this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  the patient desires full resuscitation status.",4
"operation,1.  ivor-lewis esophagogastrectomy.,2.  feeding jejunostomy.,3.  placement of two right-sided #28-french chest tubes.,4.  right thoracotomy.,anesthesia:  ,general endotracheal anesthesia with a dual-lumen tube.,operative procedure in detail: , after obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  prior to administration of general anesthesia, the patient had an epidural anesthesia placed.  in addition, he had a dual-lumen endotracheal tube placed.  the patient was placed in the supine position to begin the procedure.  his abdomen and chest were prepped and draped in the standard surgical fashion.  after applying sterile dressings, a #10-blade scalpel was used to make an upper midline incision from the level of the xiphoid to just below the umbilicus.  dissection was carried down through the linea using bovie electrocautery.  the abdomen was opened.  next, a balfour retractor was positioned as well as a mechanical retractor.  next, our attention was turned to freeing up the stomach.  in an attempt to do so, we identified the right gastroepiploic artery and arcade.  we incised the omentum and retracted it off the stomach and gastroepiploic arcade.  the omentum was divided using suture ligature with 2-0 silk.  we did this along the greater curvature and then moved to the lesser curvature where the short gastric arteries were taken down with ligation using 2-0 silk.  next, we turned our attention to performing a kocher maneuver.  this was done and the stomach was freed up.  we took down the falciform ligament as well as the caudate attachment to the diaphragm.  we enlarged the diaphragmatic hiatus so as to be able to place approximately 3 fingers into the chest.  we also did a portion of the esophageal dissection from the abdomen into the chest area.  the esophagus and the esophageal hiatus were identified in the abdomen.  we next turned our attention to the left gastric artery.  the left gastric artery was identified at the base of the stomach.  we first took the left gastric vein by ligating and dividing it using 0 silk ties.  the left gastric artery was next taken using suture ligature with silk ties followed by 2-0 stick tie reinforcement.  at this point the stomach was freely mobile.  we then turned our attention to performing our jejunostomy feeding tube.  a 2-0 vicryl pursestring was placed in the jejunum approximately 20 cm distal to the ligament of treitz.  we then used bovie electrocautery to open the jejunum at this site.  we placed a 16-french red rubber catheter through this site.  we tied down in place.  we then used 3-0 silk sutures to perform a witzel.  next, the loop of jejunum was tacked up to the abdominal wall using 2-0 silk ties.  after doing so and pulling the feeding jejunostomy out through the skin and securing it appropriately, we turned our attention to closing the abdomen.  this was done with #1 prolene.  we put in a 2nd layer of 2-0 vicryl.  the skin was closed with 4-0 monocryl.,next, we turned our attention to performing the thoracic portion of the procedure.  the patient was placed in the left lateral decubitus position.  the right chest was prepped and draped appropriately.  we then used a #10 blade scalpel to make an incision in a posterolateral, non-muscle-sparing fashion.  dissection was carried down to the level of the ribs with bovie electrocautery.  next, the ribs were counted and the 5th interspace was entered.  the lung was deflated.  we placed standard chest retractors.  next, we incised the peritoneum over the esophagus.  we dissected the esophagus to just above the azygos vein.  the azygos vein, in fact, was taken with 0 silk ligatures and reinforced with 2-0 stick ties.  as mentioned, we dissected the esophagus both proximally and distally down to the level of the hiatus.  after doing this, we backed our ng tube out to above the level where we planned to perform our pursestring.  we used an automatic pursestring and applied.  we then transected the proximal portion of the stomach with metzenbaum scissors.  we secured our pursestring and then placed a 28 anvil in the divided proximal portion of the esophagus.  the pursestring was then tied down without difficulty.  next, we tabularized our stomach using a #80 gia stapler.  after doing so, we chose a portion of the stomach more distally and opened it using bovie electrocautery.  we placed our eea stapler through it and then punched out through the gastric wall.  we connected our anvil to the eea stapler.  this was then secured appropriately.  we checked to make sure that there was appropriate muscle apposition.  we then fired the stapler.  we obtained 2 complete rings, 1 of the esophagus and 1 of the stomach, which were sent for pathology.  we also sent the gastroesophageal specimen for pathology.  of note was the fact that the frozen section showed no evidence of tumor and in the proximal distal margins.  we then turned our attention to closing the gastrostomy opening.  this was closed with 2-0 vicryl in a running fashion.  we then buttressed this with serosal 3-0 vicryl interrupted sutures.  we returned the newly constructed gastroesophageal anastomosis into the chest and covered it by covering the pleura over it.  next, we placed two #28-french chest tubes, 1 anteriorly and 1 posteriorly, taking care not to place it near the anastomosis.  we then closed the chest with #2 vicryl in an interrupted figure-of-eight fashion.  the lung was brought up.  we closed the muscle layers with #0 vicryl followed by #0 vicryl; then we closed the subcutaneous layer with 2-0 vicryl and the skin with 4-0 monocryl.  sterile dressing was applied.  the instrument and sponge count was correct at the end of the case.  the patient tolerated the procedure well and was extubated in the operating room and transferred to the icu in good condition.",36
"reason for the consult: , sepsis, possible sbp.,history of present illness: , this is a 53-year-old hispanic man with diabetes, morbid obesity, hepatitis c, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees.  he complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.  he ran out of prescription medications 1 month ago.  in the er he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24.  white blood cell count was slightly low at 4 and platelet count was only 22,000.  abdominal ultrasound showed mild-to-moderate ascites.  he was given 1 dose of zosyn and then started on levofloxacin and flagyl last night.  dr. x was called early this morning due to hypotension, sbp in the 70s.  he then changed antibiotic regiment to vancomycin and doripenem.,past medical history: , hepatitis c, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,social history: , the patient is a former smoker, reportedly quit in 2007.  he used cocaine in the past, reportedly quit in 2005.  he also has a history of alcohol abuse, but apparently quit more than 10 years ago.,allergies:,  none known.,current medications: , vancomycin, doripenem, thiamine, protonix, potassium chloride p.r.n., magnesium p.r.n., zofran. p.r.n., norepinephrine drip, and vitamin k.,review of systems: , not obtainable as the patient is drowsy and confused.,physical examination:,constitutional/vital signs:  heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 l nasal cannula.,general appearance:  the patient is drowsy.  morbidly obese.  height 5 feet 8 inches, body weight 182 kilos.,eyes:  slightly pale conjunctivae, icteric sclerae.  pupils equal, brisk reaction to light.,ears, nose, mouth and throat:  intact gross hearing.  moist oral mucosa.  no oral lesions.,neck:  no palpable neck masses.  thyroid is not enlarged on inspection.,respiratory:  regular inspiratory effort.  no crackles or wheezes.,cardiovascular:  regular cardiac rhythm.  no rales or rubs.  positive bipedal edema, 2+, right worse than left.,gastrointestinal:  globular abdomen.  soft.  no guarding, no rigidity.  tender on palpation of n right upper quadrant and epigastric area.  mildly tender on palpation of right upper quadrant and epigastric area.,lymphatic:  no cervical lymphadenopathy.,skin:  positive diffuse jaundice.  no palpable subcutaneous nodules.,psychiatric:  poor judgment and insight.,laboratory data: , white blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, h&h 9.7/28.2, platelet count 24,000.  inr 3.84, ptt more than 240.  bun and creatinine 26.8/1.2.  ast 76, alt 27, alkaline phosphatase 48, total bilirubin 17.85.  total ck 1198.6, ldh 873.2.  troponin 0.09, myoglobin 2792.  urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria.  two sets of blood cultures from 01/07/09 still pending.,radiology:,  chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures.  left knee x-rays on 01/07/09 showed advanced osteoarthritis.  abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid.  preliminary report of cat scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein.  appendix was not clearly seen, but there was no evidence of pericecal inflammation.,impression:,1.  septic shock.,2.  possible urinary tract infection.,3.  ascites, rule out spontaneous bacterial peritenonitis.,4.  hyperbilirubinemia, consider cholangitis.,5.  alcoholic liver disease.,6.  thrombocytopenia.,7.  hepatitis c.,8.  cryoglobulinemia.,recommendations:,1.  continue with vancomycin and doripenem at this point.,2.  agree with paracentesis.,3.  send ascitic fluid for cell count, differential and cultures.,4.  follow up with result of blood cultures.,5.  we will get urine culture from the specimen on admission.,6.  the patient needs hepatitis a vaccination.,additional id recommendations as appropriate upon followup.",14
"preoperative diagnosis: , left pleural effusion, parapneumonic, loculated.,postoperative diagnosis: , left pleural effusion, parapneumonic, loculated.,operation: , left chest tube placement.,iv sedation: , 5 mg of versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,procedure: , with the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  a 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  the incision was made and deepened through the different layers to reach the intercostal space.  the pleura was entered on top of the underlying rib and finger digital palpation was performed.  multiple loculations were encountered.  break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  only a small amount of fluid was noted to come out initially.  this was sent for various studies.  soft adhesions were encountered.  the plan was to obtain a chest x-ray and start activase installation.",2
"preoperative diagnosis:,  prostate cancer.,postoperative diagnosis: , prostate cancer.,operative procedure: , radical retropubic prostatectomy with pelvic lymph node dissection.,anesthesia:  ,general epidural,estimated blood loss: , 800 cc.,complications: , none.,indications for surgery: , this is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies.  he has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection.  potential complications include, but are not limited to:,1.  infection.,2.  bleeding.,3.  incontinence.,4.  impotence.,5.  deep venous thrombosis.,6.  recurrence of the cancer.,procedure in detail: , epidural anesthesia was administered by the anesthesiologist in the holding area.  preoperative antibiotic was also given in the preoperative holding area.  the patient was then taken into the operating room after which general lma anesthesia was administered.  the patient was shaved and then prepped using betadine solution.  a sterile 16-french foley catheter was inserted into the bladder with clear urine drain.  a midline infraumbilical incision was performed.  the rectus fascia was opened sharply.  the perivesical space and the retropubic space were developed bluntly.  bookwalter retractor was then placed.  bilateral obturator pelvic lymphadenectomy was performed.  the obturator nerve was identified and was untouched.  the margin for the resection of the lymph node bilaterally were the cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder.  both hemostasis and lymphostasis was achieved by using silk ties and hemo clips.  the lymph nodes were palpably normal and were set for permanent section.  the bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using metzenbaum scissors.  the puboprostatic ligament was taken down sharply.  the superficial dorsal vein complex over the prostate was bunched up by using the allis clamp and then tied by using 2-0 silk sutures.  the deep dorsal vein complex was then bunched up by using the allis over the membranous urethral area.  the dorsal vein complex was ligated by using 0 vicryl suture on a ct-1 needle.  the allis clamp was removed and the dorsal vein complex was transected by using metzenbaum scissors.  the urethra was then identified and was dissected out.  the urethral opening was made just distal to the apex of the prostate by using metzenbaum scissors.  this was extended circumferentially until the foley catheter could be seen clearly.  2-0 monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later.  the foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected.  the lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides.  the plane between denonvilliers' fascia and the perirectal fat was developed sharply.  no tension was placed on the neurovascular bundle at any point in time.  the prostate dissected off the rectal wall easily.  once the seminal vesicles were identified, the fascia covering over them were opened transversely.  the seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected.  the bladder neck was then dissected out carefully to spare most of the bladder neck muscles.  once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen.  the specimen was inspected and appeared to be completely intact.  it was sent for permanent section.  the bladder neck mucosa was then everted by using 4-0 chromic sutures.  inspection at the prostatic bed revealed no bleeding vessels.  the sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck.  once the posterior sutures had been placed, the foley was placed into the urethra and into the bladder neck.  a 20-french foley catheter was used.  the anterior sutures were then placed.  the foley was then inflated.  the bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly.  mild traction of the foley catheter was placed to assure the anastomosis was tight.  two #19-french blake drains were placed in the perivesical spaces.  these were anchored to the skin by using 2-0 silk sutures.  the instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed.  the fascia was closed in running fashion using #1 pds.  subcutaneous tissue was closed by using 2-0 vicryl suture.  skin was approximated by using metallic clips.  the patient tolerated the operation well.",36
"preoperative diagnoses:,1.  painful enlarged navicula, right foot.,2.  osteochondroma of right fifth metatarsal.,postoperative diagnoses:,1.  painful enlarged navicula, right foot.,2.  osteochondroma of right fifth metatarsal.,procedure performed:,1.  partial tarsectomy navicula, right foot.,2.  partial metatarsectomy, right foot.,history:  ,this 41-year-old caucasian female who presents to abcd general hospital with the above chief complaint.  the patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  she states that she has been diagnosed with hereditary osteochondromas.  she has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  the patient desires surgical treatment at this time.,procedure:  ,an iv was instituted by the department of anesthesia in the preoperative holding area.  the patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  copious amounts of webril were placed on the left ankle followed by a blood pressure cuff.  after adequate sedation by the department of anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  foot was then prepped and draped in the usual sterile orthopedic fashion.,foot was elevated from the operating table and exsanguinated with an esmarch bandage.  the pneumatic ankle tourniquet was then inflated to 250 mmhg.  the foot was lowered as well as the operating table.  the sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  attention was then directed to the navicular region on the right foot.  the area was palpated until the bony prominence was noted.  a curvilinear incision was made over the area of bony prominence.  at that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  the incision was then deepened with #15 blade.  all vessels encountered were ligated for hemostasis.  the dissection was carried down to the level of the capsule and periosteum.  a linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  the periosteum and the capsule were then reflected from the navicular bone at this time.  a bony prominence was noted both medially and plantarly to the navicular bone.  an osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  after resection with an osteotome there was noted to be a large plantar shelf.  the surrounding soft tissues were then freed from this plantar area.  care was taken to protect the attachments of the posterior tibial tendon as much as possible.  only minimal resection of its attachment to the fiber was performed in order to expose the bone.  sagittal saw was then used to resect the remaining plantar medial prominent bone.  the area was then smoothed with reciprocating rasp until no sharp edges were noted.  the area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  the area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 vicryl.  the subcutaneous tissues were then reapproximated with #4-0 vicryl to reduce tension from the incision and running #5-0 vicryl subcuticular stitch was performed.,attention was then directed to the fifth metatarsal.  there was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  the incision was then deepened with #15 blade.  care was taken to preserve the extensor tendon.  the incision was then created over the capsule and periosteum of the fifth metatarsal head.  capsule and periosteum were reflected both dorsally, laterally, and plantarly.  at that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  a sagittal saw was used to resect both of these osteal prominences.,all remaining sharp edges were then smoothed with reciprocating rasp.  the area was inspected for the remaining bony prominences and none was noted.  the area was flushed with copious amounts of sterile saline.  the capsule and periosteum were then reapproximated with #3-0 vicryl.  subcutaneous closure was then performed with #4-0 vicryl in order to reduce tension around the incision line.  running #5-0 subcutaneous stitch was then performed.  steri-strips were applied to both surgical sites.  dressings consisted of adaptic, soaked in betadine, 4x4s, kling, kerlix, and coban.  the pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,the patient tolerated the above procedure and anesthesia well without complications.  the patient was transferred to the pacu with vital signs stable and vascular status intact.  the patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  the patient is to follow-up with dr. x in his office as directed or sooner if any problems or questions arise.",36
"preoperative diagnoses:,1.  nasopharyngeal mass.,2.  right upper lid skin lesion.,postoperative diagnoses:,1.  nasopharyngeal tube mass.,2.  right upper lid skin lesion.,procedures performed:,1.  functional endoscopic sinus surgery.,2.  excision of nasopharyngeal mass via endoscopic technique.,3.  excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,anesthesia: , general endotracheal.,estimated blood loss: , less than 30 cc.,complications: , none.,indications for procedure: , the patient is a 51-year-old caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  the patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on ct scan.  the patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  it appears to be growing in size and is irregularly bordered.  after risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,procedure: , the patient was brought to the operating suite by anesthesia and placed on the operating table in supine position.  after this, the patient was turned to 90 degrees by the department of anesthesia.  the right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  after this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  the patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a superblade.  after this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing westcott scissors.  after this, the ________ was then hemostatically controlled with monopolar cauterization.  the patient's skin was then reapproximated with a running #6-0 prolene suture.  a mastisol along with a single steri-strip was in place followed maxitrol ointment.  attention then was drawn to the nasopharynx.  the cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  the patient had a severely deviated nasal septum more so to the right than the left.  there appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  the nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  it was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  after this, the lesion was then removed on the right side with the xps blade.  the torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  this area was taken down with the xps blade.  prior to taking down this lesion with the xps, multiple biopsies were taken with a straight biter.  after this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  the zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  again, the xps was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  after this, the patient was then hemostatically controlled with suctioned bovie cauterization.  a floseal was then placed followed by bilateral merocels and bacitracin-coated ointment.  the patient's meroceles were then tied together to the patient's forehead and the patient was then turned back to the anesthesia.  the patient was extubated in the operating room and was transferred to the recovery room in stable condition.  the patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  the patient will be sent home with a prescription for keflex 500 mg one p.o. b.i.d, and tylenol #3 one to two p.o. q.4-6h. pain #30.",36
"reason for the consult:,  nonhealing right ankle stasis ulcer.,history of present illness: , this is a 52-year-old native american-indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per dr. x. i was consulted for nonhealing right ankle stasis ulcer.  there is a concern that the patient had a low-grade fever of 100.2 early this morning.  the patient otherwise feels well.  he was not even aware of the fever.  he does have some ankle pain, worse on the right than the left.  old medical records were reviewed.  he has multiple hospitalizations for leg cellulitis.  multiple wound cultures have repeatedly grown pseudomonas, enterococcus, and stenotrophomonas in the past.  klebsiella and enterobacter have also grown in the few wound cultures at some point.  the patient has been following up at the wound center as an outpatient and was referred to dr. x for definitive surgical management.,review of systems:,constitutional:  no malaise.  positive recent low-grade fevers.  no chills.,heent:  no acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  no sore throat.,cardiac:  no chest pain or cough.,gastrointestinal:  no nausea, vomiting or diarrhea.,all other systems were reviewed and were negative.,past medical history:  ,hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,social history: , the patient admits to heavy alcohol drinking in the past, quit several years ago.  he is also a former cigarette smoker, quit several years ago.,allergies:,  none known.,current medications:,  primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, colace, amlodipine, zinc sulfate, lortab p.r.n., multivitamins with minerals.,physical examination:,constitutional/vital signs:  heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,general appearance:  the patient is awake, alert, and not in cardiorespiratory distress.  height 6 feet 1.5 inches, body weight 125.26 kilos.,eyes:  pink conjunctivae, anicteric sclerae.  pupils equal, brisk reaction to light.,ears, nose, mouth and throat:  intact gross hearing.  moist oral mucosa.  no oral lesions.,neck:  no palpable neck masses.  thyroid is not enlarged on inspection.,respiratory:  regular inspiratory effort.  no crackles or wheezes.,cardiovascular:  regular cardiac rhythm.  no thrills or rubs.,gastrointestinal:  normoactive bowel sounds.  soft.  no guarding or rigidity.,lymphatic:  no cervical lymphadenopathy.,musculoskeletal:  good range of motion of upper and lower extremities.,skin:  there is hyperpigmentation involving the distal calf of both legs.  there is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  there is warmth, but minimal tenderness on palpation of this area.  there is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  wound edges are poorly defined.,psychiatric:  appropriate mood and affect, oriented x3.  fair judgment and insight.,laboratory results: , white blood cell count from 01/28/09 is 5.8 with 64% neutrophils, h&h 11.3/33.8, and platelet count 176,000.  bun and creatinine 9.2/0.52.  albumin 3.6, ast 25, alt 9, alk phos 87, and total bilirubin 0.6.  one wound culture from right leg wound culture from 01/27/09 noted with young growth.  left leg wound culture from 01/27/09 also with young growth.,radiology:,  chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  no absolute findings.,impression:,1.  fevers.,2.  right leg/ankle cellulitis.,3.  chronic recurrent bilateral ankle venous ulcers.,4.  multiple previous wound cultures positive for pseudomonas, enterococcus, and stenotrophomonas.,5.  hypertension.,recommendations:,1.  we have ordered 2 sets of blood cultures.,2.  agree with daptomycin and primaxin iv.,3.  follow up result of wound cultures.,4.  i will order an mri of the right ankle to check for underlying osteomyelitis.,additional id recommendations as appropriate upon followup.",14
"procedure:,  left heart catheterization, left ventriculography, selective coronary angiography.,indication: , this lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  this was felt to be related largely to chronic obstructive lung disease.  she had dynamic t-wave changes in precordial leads.  cardiac enzymes were indeterminate.  she was evaluated by dr. x and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  the patient understood and agreed to proceed.,description of the procedure: , the patient was brought to the cardiac catheterization laboratory.  under versed and fentanyl sedation, the right groin was sterilely prepped and draped.  local anesthesia was obtained with 2% xylocaine.  the right femoral artery was entered using modified seldinger technique and a 4-french introducer sheath placed in that vessel.  through the indwelling femoral arterial sheath, a jl4 4-french catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  ascending aortic root pressures obtained.  this catheter was utilized in an attempt to cannulate the left coronary ostium.  this catheter was too small, was exchanged for a jl5 4-french catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,this catheter was then exchanged for a 4-french right coronary catheter, which was advanced over the wire to the ascending aorta.  the catheter appropriately aspirated and flushed.  the catheter was advanced in the right coronary artery.  multiple views of that vessel were obtained.  the catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  this catheter was then exchanged for a 4-french pigtail catheter, which was advanced over the wire to the ascending aorta.  the catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,following this, left ventriculography was performed in a 30-degree rao projection using 30 ml of contrast injected over 3 seconds.  post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  videotapes were then reviewed.  it was elected to terminate the procedure at that point in time.,the vascular sheath was removed and manual compression carried out.  excellent hemostasis was obtained.  the patient tolerated the procedure without complication.,results of procedure,1.  ,hemodynamics:,  left ventricular end-diastolic filling pressure was 24.  there was no gradient across the aortic valve.,2.  ,left ventriculography: , left ventriculography demonstrated well-preserved left ventricular systolic function.  mild inferobasilar hypokinesis was noted.  no significant mitral regurgitation noted.  ejection fraction was estimated at 60%.,3.  ,coronary arteriography,a.  ,left main coronary: , the left main coronary was patent.,b.  ,left anterior descending coronary artery:,  left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,c.  ,circumflex coronary artery:,  circumflex coronary artery was occluded at its origin.,d.  ,right coronary artery,.  right coronary artery was occluded in its mid portion.,4.  ,saphenous vein graft angiography,a.  ,saphenous vein graft to the diagonal branch: , the saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  excellent flow was noted in the diagonal system with some retrograde flow.,b.  there was retrograde flow as well in the left anterior descending system.,c.  ,saphenous vein graft to the obtuse marginal system:,  saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  there was no graft disease noted.  excellent flow was noted in the bifurcating marginal system.,d.  ,saphenous vein graft to right coronary artery:,  saphenous vein graft to right coronary was widely patent with no graft disease.  origin and insertion sites were free of disease.  distal flow in the graft to the posterior descending was normal.,5.  ,left internal mammary artery angiography: , left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  there was no focal disease noted, inserted into the mid-to-distal lad which was a small-caliber vessel.  retrograde filling of a small septal system was noted.,summary of results,1.  elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.",36
"procedure: , bilateral l5, s1, s2, and s3 radiofrequency ablation.,indication: , sacroiliac joint pain.,informed consent: , the risks, benefits and alternatives of the procedure were discussed with the patient.  the patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,the risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and cns side effects with possible of vascular entry of medications.  i also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,the patient was informed both verbally and in writing.  the patient understood the informed consent and desired to have the procedure performed.,procedure: , oxygen saturation and vital signs were monitored continuously throughout the procedure.  the patient remained awake throughout the procedure in order to interact and give feedback.  the x-ray technician was supervised and instructed to operate the fluoroscopy machine.,the patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  the skin over and surrounding the treatment area was cleaned with betadine.  the area was covered with sterile drapes, leaving a small window opening for needle placement.  fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine.,with fluoroscopy, a 20 gauge 10-mm bent teflon coated needle was gently guided into the groove between the sap and the sacrum for the dorsal ramus of l5 and the lateral border of the posterior sacral foramen, for the lateral branches of s1, s2, and s3.  also, fluoroscopic views were used to ensure proper needle placement.,the following technique was used to confirm correct placement.  motor stimulation was applied at 2 hz with 1 millisecond duration.  no extremity movement was noted at less than 2 volts.  following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  at each level, after syringe aspiration with no blood return, 0.5 ml of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  after completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,all injected medications were preservative free.  sterile technique was used throughout the procedure.,additional details:  ,none.,complications: , none.,discussion: , post-procedure vital signs and oximetry were stable.  the patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  the patient was told to resume all medications.  the patient was told to be in relative rest for 1 day but then could resume all normal activities.,the patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,follow up appointment was made at pm&r spine clinic in approximately one to two weeks.",31
"preoperative diagnoses,1.  empyema thoracis.,2.  need for intravenous antibiotics.,postoperative diagnoses,1.  empyema thoracis.,2.  need for intravenous antibiotics.,procedure:,  central line insertion.,description of procedure: , with the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  xylocaine 1% was infiltrated and with the patient in the trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  the triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  the catheter was fixed to the skin with sutures.  the dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.",36
"preoperative diagnoses,1.  emg-proven left carpal tunnel syndrome.,2.  tenosynovitis of the left third and fourth fingers at the a1 and a2 pulley level.,3.  dupuytren's nodule in the palm.,postoperative diagnoses,1.  emg-proven left carpal tunnel syndrome.,2.  tenosynovitis of the left third and fourth fingers at the a1 and a2 pulley level.,3.  dupuytren's nodule in the palm.,procedure: , left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers; injection of dupuytren's nodule, left palm.,anesthesia: , local plus iv sedation (mac).,estimated blood loss:  ,zero.,specimens:  ,none.,drains: , none.,procedure detail: , patient brought to the operating room.  after induction of iv sedation the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% xylocaine and 0.5% marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery.  routine prep and drape was employed.  arm was exsanguinated by means of elevation of esmarch elastic tourniquet and tourniquet inflated to 250 mmhg pressure.  hand was positioned palm up in the lead hand-holder.  a short curvilinear incision about the base of the thenar eminence was made.  skin was sharply incised.  sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin.  care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm.  proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve.  retinacular flap was retracted radially to expose the contents of the carpal canal.  median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing.  locally adherent tenosynovium was present and this was carefully dissected free.  additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal.  epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium.  when this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures.  a syringe with 3 cc of kenalog-10 and 3 cc of 1% xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger a1 and a2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger a1/a2 pulley tendon sheath using standard tendon sheath injection technique; 1 cc was injected into the dupuytren's nodule in the midpalm to relieve local discomfort.  routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive ace wrap was applied.  tourniquet was deflated.  good vascular color and capillary refill were seen to return to the tips of all digits.  patient discharged to the ambulatory recovery area and from there discharged home.  discharge medication is darvocet-n 100, 30 tablets, one to two po q.4h. p.r.n.  patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery.  she was asked to keep the dressings clean, dry and intact and follow up in my office.",36
"clothing: , the body is clad in a light green hospital gown, which is intact, dry and clean. there is no jewelry present.,external examination:,  the body is that of a well-developed, well-nourished white woman appearing the offered age of 39 years. the body measures 71 inches and weighs 178 pounds.,the unembalmed body is well preserved and cool to touch due to refrigeration. rigor mortis is fully developed in the major muscle groups. livor mortis is fixed and purple posteriorly except over pressure points. however, during initial examination in the emergency room, there was no rigor and lividity was at a minimum and unfixed. the skin is intact and shows no evidence of trauma except for medical intervention. the scalp hair is blond and measures up to 5 inches in length in the frontal area and up to 19 inches in length in the back and on top of the head. there are multiple blonde hair extensions including several pink strands attached to the natural hair, which shows light brown roots. the irides are hazel and the pupils are equal, each measuring 0.5 centimeter in diameter. the corneae are clear and the sclerae and conjunctivae are free of petechiae. the nasal bones are intact by palpation. the nares are patent and contain no foreign matter. there is a 3-millimeter raised nodule on the right side of the nose. the natural teeth are in good condition. the frenula are intact. the oral mucosa and tongue are free of injuries. the external ears have no injuries. there are bilateral earlobe piercings; no earring or jewelry were present. there are no earlobe creases.,the neck is symmetrical and shows no masses or injuries. the trachea is in the midline. the shoulders are symmetrical and are free of scars.,the chest is symmetrical and shows no evidence of injury. there were bilateral breasts with asymmetry of the left breast due to scarring. the flat abdomen has no injuries. there are piercings above and below the umbilicus. the back is symmetrical. the buttocks have inconspicuous small scars, bilaterally. there is a flat, round scar on the lower aspect of the left buttock approximately 1/2 inch in diameter.,the genitalia are those of a normally developed adult woman. there is no evidence of injury. the anus is unremarkable.,the upper extremities are symmetrical and have no injuries. the fingernails are long and clean. there is a linear 1/2 inch scar on the anterior right forearm. two parallel linear scars measuring 1 inch and 2 inches are on the anterior surface of the left forearm.  the lower extremities are symmetrical. the toenails are short and clean. there is no edema of the legs or ankles.  there is no abnormal motion of the neck, the shoulders, the elbows, the wrists, the fingers, the hips and ankles. there is no bony crepitus or cutaneous crepitus present.,evidence of injury: , a dissection of the posterior neck and upper back show a 2-1/4 x 2-3/4 inch reddish, recent contusion of the subcutaneous and superficial muscle layer of the left posterior shoulder. a recent, reddish, 1-3/4 x 1-1/2 inch reddish contusion is present on the right posterior shoulder involving the superficial muscular layer.,evidence of recent medical treatment: , a properly positioned size 8 endotracheal tube retained by a thomas clamp is present at the mouth with the marker 22 at the anterior teeth.  ,electrocardiogram pads are on the anterior chest in the following order: two on the right anterior shoulder, two on the left anterior shoulder, one on the upper anterior left arm, one each on the anterior side, one each on the anterior leg.,two defibrillator pads are present: one to the right of the midline, above the right breast, and one to the left of the midline, below the left breast.,there is intravenous line placement at the right anterior neck with hemorrhage into the anterior strap muscles of the neck. one recent needle puncture mark is in the right antecubital fossa and two recent needle puncture marks are at the anterior left elbow with surrounding ecchymoses. there is one recent needle puncture into the medial one-third of the left anterior forearm with surrounding ecchymosis. a recent needle puncture mark is at the left anterior wrist with surrounding reddish ecchymosis, 1 inch in diameter.,other identifying features: , there are multiple scars and tattoos on the body.,scars:,  a 3/4 x 1/2 inch flat scar is on the upper inner aspect of the right breast quadrant. a 1/2 x 3/8-inch scar is on the medial aspect of the left nipple. there are circular scars adjacent to both areolae. the right inframammary skin has a linear transverse 3/4 inch remote ""chest tube"" scar. there were bilateral inframammary and transverse linear 3-3/4 inch scars compatible with left and right mammoplasty with breast implants. there are circular scars surrounding piercings above and below the umbilicus. a flat 3/8 inch in diameter scar is present on the middle third of the anterior surface of the right thigh. lateral to this scar is a 1/2 inch in diameter flat scar. there are several scattered small inconspicuous scars on both buttocks. there is a cluster of multiple, parallel, linear, well-healed scars on the anterior and lateral aspects of the right leg covered by a tattoo.,tattoos: , there is a pair of red lips in the right lower abdominal quadrant.,two red cherries are on the right mid pelvis.,a ""playboy bunny"" is on the left anterior mid pelvis.,the words ""daniel"" and ""papas"" are on the mid anterior pelvis region.,a mixed tattoo on the right lower leg and ankle represents: christ's head; our lady of,guadalupe; the holy bible; the naked torso of a woman; the smiling face of marilyn monroe; a,cross; a heart and shooting flames.,a mermaid on a flower bed with a pair of lips underneath it laying across the lower back.,internal examination:  ,the body was opened with the usual y incision. the breast tissues, when incised, revealed bilateral implants, each containing 700ml of clear fluid. the implants were surrounded by a thick connective tissue capsule with a thick yellow fluid. the content of each capsule was collected for bacteriological cultures.,body cavities: , the muscles of the chest and abdominal wall are normal in color and consistency. the lungs are neither hyperinflated nor atelectatic when the pleural cavities are opened. the right lung shows adherence to the parietal pleura and to the diaphragm interiorly. the ribs, sternum and spine exhibit no fractures. the right and left pleural cavities have no free fluid. there are extensive right pleural fibrous adhesions. the mediastinum is in the midline. the pericardial sac has a normal amount of clear yellow fluid. the diaphragm has no abnormality. the subcutaneous abdominal fat measures 3 centimeters in thickness at the umbilicus. the abdominal cavity is lined with glistening serosa and has no collections of free fluid. the organs are normally situated. the mesentery and omentum are unremarkable.,neck: , the soft tissues and the strap muscles of the neck, aside from the previously described focal hemorrhages, exhibit no abnormalities. the hyoid bone and the cartilages of the larynx and thyroid are intact and show no evidence of injury. the larynx and trachea are lined by smooth pink-tan mucosa, are patent and contain no foreign matter. there is a focal area of reddish hyperemia at the carina associated with the endotracheal tube. the epiglottis and vocal cords are unremarkable. the cervical vertebral column is intact. the carotid arteries and jugular veins are unremarkable.,cardiovascular system: , the heart and great vessels contain dark red liquid blood and little postmortem clots. the heart weighs 305 grams. the epicardial surface has a normal amount of glistening, yellow adipose tissue. the coronary arteries are free of atherosclerosis. the cut surfaces of the brown myocardium show no evidence of hemorrhage or necrosis.,the pulmonary trunk and arteries are opened in situ and there is no evidence of thromboemboli. the intimal surface of the aorta is smooth with a few scattered yellow atheromata. the ostia of the major branches are of normal distribution and dimension. the inferior vena cava and tributaries have no antemortem clots (see attached cardiopathology report for additional details).,respiratory system:  ,the lungs weigh 550 grams and 500 grams, right and left, respectively. there is a small amount of subpleural anthracotic pigment within all the lobes. the pleural surfaces are free of exudates; right-sided pleural adhesions have been described above. the trachea and bronchi have smooth tan epithelium. the cut surfaces of the lungs are red-pink and have mild edema. the lung parenchyma is of the usual consistency and shows no evidence of neoplasm, consolidation, thromboemboli, fibrosis or calcification.,hepatobiliary system:  ,the liver weighs 2550 grams. the liver edge is somewhat blunted. the capsule is intact. the cut surfaces are red-brown and of normal consistency. there are no focal lesions. the gallbladder contains 15 milliliters of dark green bile. there are no stones. the mucosa is unremarkable. the large bile ducts are patent and non-dilated.,hemolymphatic system:  ,the thymus is not identified. the spleen weighs 310 grams. the capsule is shiny, smooth and intact. the cut surfaces are firm and moderately congested. the lymphoid tissue in the spleen is within a normal range. the lymph nodes throughout the body are not enlarged.,gastrointestinal system:  ,the tongue shows a small focus of submucosal hemorrhage near the tip. the esophagus is empty and the mucosa is unremarkable. the stomach contains an estimated 30 milliliters of thick sanguinous fluid. the gastric mucosa shows no evidence or ulceration. there is a mild flattening of the rugal pattern within the antrum with intense hyperemia. the duodenum contains bile-stained thick tan fluid. the jejunum, ileum, and the colon contain yellowish fluid with a thick, cloudy, particulate matter. there is no major alteration to internal and external inspection and palpation except for a yellowish/white shiny discoloration of the mucosa. the vermiform appendix is identified. the pancreas is tan, lobulated and shows no neoplasia, calcification or hemorrhage.,there are no intraluminal masses or pseudomenbrane.,urogenital system:  ",0
"preoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  cervical spondylosis with herniated nucleus pulposus, c5-c6.,postoperative diagnoses,1.  neck pain with bilateral upper extremity radiculopathy, left more than the right.,2.  cervical spondylosis with herniated nucleus pulposus, c5-c6.,operative procedures,1.  anterior cervical discectomy with decompression, c5-c6.,2.  arthrodesis with anterior interbody fusion, c5-c6.,3.  spinal instrumentation, c5-c6 using pioneer 18-mm plate and four 14 x 4.0 mm screws (all titanium).,4.  implant using peek 7 mm.,5.  allograft using vitoss.,drains: , round french 10 jp drain.,fluids:  ,1200 cc of crystalloids.,urine output: , no foley catheter.,specimens: , none.,complications: , none.,anesthesia: , general endotracheal anesthesia.,estimated blood loss: , less than 50 cc.,indications for the operation:,  this is a case of a very pleasant 38-year-old caucasian female who has been complaining over the last eight years of neck pain and shoulder pain radiating down across the top of her left shoulder and also across her shoulder blades to the right side, but predominantly down the left upper extremity into the wrist.  the patient has been diagnosed with fibromyalgia and subsequently, has been treated with pain medications, anti-inflammatories and muscle relaxants.  the patient's symptoms continued to persist and subsequently, an mri of the c-spine was done, which showed disc desiccation, spondylosis and herniated disk at c5-c6, an emg and cv revealed a presence of mild-to-moderate carpal tunnel syndrome.  the patient is now being recommended to undergo decompression and spinal instrumentation and fusion at c5-c6.  the patient understood the risks and benefits of the surgery.  risks include but not exclusive of bleeding and infection.  bleeding can be in the form of soft tissue bleeding, which may compromise airway for which she can be brought emergently back to the operating room for emergent evacuation of the hematoma as this may cause weakness of all four extremities, numbness of all four extremities, as well as impairment of bowel and bladder function.  this could also result in dural tear with its attendant symptoms of headache, nausea, vomiting, photophobia, and posterior neck pain as well as the development of pseudomeningocele.  should the symptoms be severe or the pseudomeningocele be large, she can be brought back to the operating room for repair of the csf leak and evacuation of the pseudomeningocele.  there is also the risk of pseudoarthrosis and nonfusion, for which she may require redo surgery at this level.  there is also the possibility of nonimprovement of her symptoms in about 10% of cases.  the patient understands this risk on top of the potential injury to the esophagus and trachea as well as the carotid artery.  there is also the risk of stroke, should an undiagnosed plaque be propelled into the right cerebral circulation.  the patient also understands that there could be hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  she understood these risks on top of the risks of anesthesia and gave her consent for the procedure.,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, the patient was positioned supine on the operating table with the neck placed on hyperextension and the head supported on a foam doughnut.  a marker was placed.  this verified the level to be at the c5-c6 level and incision was then marked in a transverse fashion starting from the midline extending about 5 mm beyond the anterior border of the sternocleidomastoid muscle.  the area was then prepped with duraprep after the head was turned 45 degrees to the left.,after sterile drapes were laid out, an incision was made using a scalpel blade #10.  wound edge bleeders were carefully controlled with bipolar coagulation and the platysma was cut using a hot knife in a transverse fashion.  dissection was then carried underneath the platysma superiorly inferiorly.  the anterior border of the sternocleidomastoid was identified and dissection was carried out lateral to the esophagus to trachea as well as medial to the carotid sheath in the sternocleidomastoid muscle.  the prevertebral fascia was noted to be taken her case with a lot of fat deposition.  bipolar coagulation of bleeders was done; however, branch of the superior thyroid artery was ligated with hemoclips x4.  after this was completed, a localizing x-ray verified the marker to be at the c6-c7 level.  we proceeded to strip the longus colli muscles off the vertebral body of the c5 and c6.  self-retaining retractor was then laid down.  an anterior osteophyte was carefully drilled using a midas 5-mm bur and the disk together with the inferior endplate of c5 and the superior endplate of c6 was also drilled down with the midas 5-mm bur.  this was later followed with a 3-mm bur and the disk together with posterior longitudinal ligament was removed using kerrison's ranging from 1 to 4 mm.  the herniation was noted on the right.  however, there was significant neuroforaminal stenosis on the left.  decompression on both sides was done and after this was completed, a valsalva maneuver showed no evidence of any csf leakage.  the area was then irrigated with saline with bacitracin solution.  a 7 mm implant with its inferior packed with vitoss was then laid down and secured in place with four 14 x 4.0 mm screws and plate 18 mm, all of which were titanium.  x-ray after this placement showed excellent position of all these implants and screws and _____ and the patient's area was also irrigated with saline with bacitracin solution.  a round french 10 jp drain was then laid down and exteriorized through a separate stab incision on the patient's right inferiorly.  the catheter was then anchored to the skin with a nylon 3-0 stitch and connected to a sterile draining system.  the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures for the platysma, vicryl subcuticular 4-0 stitch for the dermis, and the wound was reinforced with dermabond.  dressing was placed only at the exit site of the catheter.  c-collar was placed.  the patient was extubated and transferred to recovery.",21
"preoperative diagnosis: , herniated nucleus pulposus, c5-c6, with spinal stenosis.,postoperative diagnosis: , herniated nucleus pulposus, c5-c6, with spinal stenosis.,procedure: , anterior cervical discectomy with fusion c5-c6.,procedure in detail: , the patient was placed in supine position.  the neck was prepped and draped in the usual fashion.  an incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  skin and subcutaneous tissue were divided sharply.  trachea and esophagus were retracted medially.  carotid sheath was retracted laterally.  longus colli muscles were dissected away from the vertebral bodies of c5-c6.  we confirmed our position by taking intraoperative x-rays.  we then used the operating microscope and cleaned out the disk completely.  we then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  we then used the depuy dynamic plate with 14-mm screws.  jackson-pratt drain was placed in the prevertebral space and brought out through a separate incision.  the wound was closed in layers using 2-0 vicryl for muscle and fascia.  the blood loss was less than 10-20 ml.  no complication.  needle count, sponge count, and cottonoid count was correct.",25
"acromioclavicular joint injection,procedure:,:  informed consent was obtained from the patient.  all possible complications were mentioned including joint swelling, infection, and bruising.  the joint was prepared with betadine and alcohol.  then 1 ml of depo-medrol and 2 ml of 0.25% marcaine were injected using the anterior approach.  this was injected easily using a 25 gauge needle with the patient sitting and the shoulder propped up on a pillow.  the joint was entered easily without any great difficulty.  aspiration was performed prior to the injection to make sure there was no intravascular injection.  there were no complications and good relief of symptoms.,post procedure instructions:, the patient has been asked to report to us any redness, swelling, inflammation, or fevers.  the patient has been asked to restrict the use of the * extremity for the next 24 hours.",26
"delivery note: , on 12/23/08 at 0235 hours, a 23-year-old g1, p0, white female, gbs negative, under epidural anesthesia, delivered a viable female infant with apgar scores of 7 and 9.  points taken of for muscle tone and skin color.  weight and length are unknown at this time.  delivery was via spontaneous vaginal delivery.  nuchal cord x1 were tight and reduced.  infant was delee suctioned at perineum.  cord clamped and cut and infant handed to the awaiting nurse in attendance.  cord blood sent for analysis, intact.  meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  a 15 units of pitocin was started after delivery of the placenta.  uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 vicryl in a normal fashion.  estimated blood loss was approximately 400 ml.  the patient was taken to the recovery room in stable condition.  infant was taken to newborn nursery in stable condition.  the patient tolerated the procedure well.  the only intrapartum event that occurred was thick meconium.  otherwise, there were no other complications.  the patient tolerated the procedure well.",36
"subjective:,  the patient is a 44-year-old white female who is here today with multiple problems.  the biggest concern she has today is her that left leg has been swollen.  it is swollen for three years to some extent, but worse for the past two to three months.  it gets better in the morning when she is up, but then through the day it begins to swell again.  lately it is staying bigger and she somewhat uncomfortable with it being so large.  the right leg also swells, but not nearly like the left leg.  the other problem she had was she has had pain in her shoulder and back.  these occurred about a year ago, but the pain in her left shoulder is of most concern to her.  she feels like the low back pain is just a result of a poor mattress.  she does not remember hurting her shoulder, but she said gradually she has lost some mobility.  it is hard time to get her hands behind her back or behind her head.  she has lost strength in the left shoulder.  as far as the blood count goes, she had an elevated white count.  in april of 2005, dr. xyz had asked dr. xyz to see her because of the persistent leukocytosis; however, dr. xyz felt that this was not a problem for the patient and asked her to just return here for follow up.  she also complains of a lot of frequency with urination and nocturia times two to three.  she has gained weight; she thinks about 12 pounds since march.  she now weighs 284.  fortunately, her blood pressure is staying stable.  she takes atenolol 12.5 mg per day and takes lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much.  she denies chest pain, but she does feel like she is becoming gradually more short of breath.  she works for the city of wichita as bus dispatcher, so she does sit a lot, and just really does not move around much.  towards the end of the day her leg was really swollen.  i reviewed her lab work.  other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check.,objective:,general:  the patient is a very pleasant 44-year-old white female quite obese.,vital signs:  blood pressure:  122/70.  temperature:  98.6.,heent:  head:  normocephalic.  ears:  tms intact.  eyes:  pupils round, and equal.  nose:  mucosa normal.  throat:  mucosa normal.,lungs:  clear.,heart:  regular rate and rhythm.,abdomen:  soft and obese.,extremities:  a lot of fluid in both legs, but especially the left leg is really swollen.  at least 2+ pedal edema.  the right leg just has a trace of edema.  she has pain in her low back with range of motion.  she has a lot of pain in her left shoulder with range of motion.  it is hard for her to get her hand behind her back.  she cannot get it up behind her head.  she has pain in the anterior left shoulder in that area.,assessment:,1.  multiple problems including left leg swelling.,2.  history of leukocytosis.,3.  joint pain involving the left shoulder, probably impingement syndrome.,4.  low back pain, chronic with obesity.,5.  obesity.,6.  frequency with urination.,7.  tobacco abuse.,plan:,1.  i will schedule for a venous doppler of the left leg and will have her come back in the morning for a cbc and a metabolic panel.  we will start her on detrol 0.4 mg one daily and also started on mobic 15 mg per day.,2.  elevate her leg as much as possible and wear support hose if possible.  keep her foot up during the day.  we will see her back in two weeks.  we will have the results of the doppler, the lab work and see how she is doing with the detrol and the joint pain.  if her shoulder pain is not any better, we probably should refer her on over to orthopedist.  we did do x-rays of her shoulder today that did not show anything remarkable.  see her in two weeks or p.r.n.",33
"technique: , sequential axial ct images were obtained from the vertex to the skull base without contrast.,findings: , there is mild generalized atrophy.  scattered patchy foci of decreased attenuation are seen within the sub cortical and periventricular white matter compatible with chronic small vessel ischemic changes.  the brain parenchyma is otherwise normal in attenuation with no evidence of mass, hemorrhage, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  the visualized paranasal sinuses and mastoid air cells are clear.  the bony calvarium and skull base are within normal limits.  ,impression: , no acute abnormalities.",31
"reason for exam: , dynamic st-t changes with angina.,procedure:,1.  selective coronary angiography.,2.  left heart catheterization with hemodynamics.,3.  lv gram with power injection.,4.  right femoral artery angiogram.,5.  closure of the right femoral artery using 6-french angioseal.,procedure explained to the patient, with risks and benefits.  the patient agreed and signed the consent form.,the patient received a total of 2 mg of versed and 25 mcg of fentanyl for conscious sedation.  the patient was draped and dressed in the usual sterile fashion.  the right groin area infiltrated with lidocaine solution.  access to the right femoral artery was successful, okayed with one attempt with anterior wall stick.  over a j-wire, 6-french sheath was introduced using modified seldinger technique.,over the j-wire, a jl4 catheter was passed over the aortic arch.  the wire was removed.  catheter was engaged into the left main.  multiple pictures with rao caudal, ap cranial, lao cranial, shallow rao, and lao caudal views were all obtained.  catheter disengaged and exchanged over j-wire into a jr4 catheter, the wire was removed.  catheter with counter-clock was rotating to the rca one shot with lao, position was obtained.  the cath disengaged and exchanged over j-wire into a pigtail catheter.  pigtail catheter across the aortic valve.  hemodynamics obtained.  lv gram with power injection of 36 ml of contrast was obtained.,the lv gram assessed followed by pullback hemodynamics.,the catheter exchanged out and the right femoral artery angiogram completed to the end followed by the removal of the sheath and deployment of 6-french angioseal with no hematoma.  the patient tolerated the procedure well with no immediate postprocedure complication.,hemodynamics:  ,the aortic pressure was 117/61 with a mean pressure of 83.  the left ventricular pressure was 119/9 to 19 with left ventricular end-diastolic pressure of 17 to 19 mmhg.  the pullback across the aortic valve reveals zero gradient.,anatomy:  ,the left main showed minimal calcification as well as the proximal lad.  no stenosis in the left main seen, the left main bifurcates in to the lad and left circumflex.,the lad was a large and a long vessel that wraps around the apex showed no focal stenosis or significant atheromatous plaque and the flow was timi 3 flow in the lad.  the lad gave off two early diagonal branches.  the second was the largest of the two and showed minimal lumen irregularities, but no focal stenosis.,left circumflex was a dominant system supplying three obtuse marginal branches and distally supplying the pda.  the left circumflex was large and patent, 6.0 mm in diameter.  all three obtuse marginal branches appeared to be with no significant stenosis.,the obtuse marginal branch, the third om3 showed at the origin about 30 to 40% minimal narrowing, but no significant stenosis.  the pda was wide, patent, with no focal stenosis.,the rca was a small nondominant system with no focal stenosis and supplying the rv marginal.,lv gram showed that the lv ef is preserved with ef of 60%.  no mitral regurgitation identified.,impression:,1.  patent coronary arteries with normal left anterior descending, left circumflex, and dominant left circumflex system.,2.  nondominant right, which is free of atheromatous plaque.,3.  minimal plaque in the diagonal branch ii, and the obtuse,marginal branch iii, with no focal stenosis.,4.  normal left ventricular function.,5.  evaluation for noncardiac chest pain would be recommended.",36
"postoperative day #1, total abdominal hysterectomy,subjective: , the patient is alert and oriented x3 and sitting up in bed.  the patient has been ambulating without difficulty.  the patient is still npo.  the patient denies any new symptomatology from  6/10/2009.  the patient has complaints of incisional tenderness.  the patient was given a full explanation about her clinical condition and all her questions were answered.,objective:,vital signs:  afebrile now.  other vital signs are stable.,gu:  urinating through foley catheter.,abdomen:  soft, negative rebound.,extremities:  without homans, nontender.,back:  without cva tenderness.,genitalia:  vagina, slight spotting.  wound dry and intact.,assessment:,  normal postoperative course.,plan:,1.  follow clinically.,2.  continue present therapy.,3.  ambulate with nursing assistance only.,",22
"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.",25
"exam:  ,ct kub.,reason for exam: , flank pain.,technique:,  noncontrast ct abdomen and pelvis per renal stone protocol.,correlation is made with the prior examination dated 01/16/09.,findings: , there is no intrarenal stone or obstruction bilaterally.  there is no hydronephrosis, ureteral dilatation.  there are calcifications about the pelvis including one in the left upper pelvis, but these are stable from the prior study and there is no upstream ureteral dilatation, the findings therefore are favored to represent phleboliths.  the bladder is nearly completely decompressed.  there is no asymmetric renal enlargement or perinephric stranding as secondary evidence of obstruction.,the appendix is normal.  there is no evidence for a pericolonic inflammatory process or small bowel obstruction.,dedicated scan to the pelvis disclosed the aforementioned presumed phleboliths.  there is no pelvic free fluid or adenopathy.,lung bases appear clear.  given the lack of contrast, liver, spleen, adrenal glands, and the pancreas appear grossly unremarkable.  the gallbladder has been resected.  there is no abdominal free fluid or pathologic adenopathy.,impression:,1. no renal stone or evidence of obstruction.  stable appearing pelvic calcifications likely indicate phleboliths.,2. normal appendix.",31
"subjective:,  the patient returns to the pulmonary medicine clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  she was last seen in the pulmonary medicine clinic in january 2004.  since that time, her respiratory status has been quite good.  she has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  she denies any problems with cough or sputum production.  no fevers or chills.  recently, she has had a bit more problems with fatigue.  for the most part, she has had no pulmonary limitations to her activity.,current medications:,  synthroid 0.112 mg daily; prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; plaquenil 200 mg b.i.d.; imuran 100 mg daily; advair one puff b.i.d.; premarin 0.3 mg daily; lipitor 10 mg monday through friday; actonel 35 mg weekly; and aspirin 81 mg daily.  she is also on calcium, vitamin d, vitamin e, vitamin c and a multivitamin.,allergies:,  penicillin and also intolerance to shellfish.,review of systems:,  noncontributory except as outlined above.,examination:,general:  the patient was in no acute distress.,vital signs:  blood pressure 122/60, pulse 72 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, but clear.,cardiovascular:  regular rate and rhythm.,abdomen:  soft and nontender.,extremities:  without edema.  no skin lesions.,o2 saturation was checked at rest.  on room air it was 96% and on ambulation it varied between 94% and 96%.  chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  she has not had the previous chest x-ray with which to compare; however, i did compare the markings was less prominent when compared with previous ct scan.,assessment:,1.  lupus with mild pneumonitis.,2.  respiratory status is stable.,3.  increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,plan:,  at this time, i have recommended to continue her current medications.  we would like to see her back in approximately four to five months, at which time i would like to recheck her pulmonary function test as well as check cat scan.  at that point, it may be reasonable to consider weaning her imuran if her pulmonary status is stable and the lupus appears to be under control.",33
"preop diagnosis: , basal cell ca.,postop diagnosis:,  basal cell ca.,location:  ,medial right inferior helix.,preop size:,  1.4 x 1 cm,postop size: , 2.7 x 2 cm,indication: , poorly defined borders.,complications: , none.,hemostasis: , electrodessication.,planned reconstruction: , wedge resection advancement flap.,description of procedure: , prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,the clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  with each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the mohs fresh tissue technique.  a map was prepared to correspond to the area of skin from which it was excised.  the tissue was prepared for the cryostat and sectioned.  each section was coded, cut and stained for microscopic examination.  the entire base and margins of the excised piece of tissue were examined by the surgeon.  areas noted to be positive on the previous stage (if applicable) were removed with the mohs technique and processed for analysis.,no tumor was identified after the final stage of microscopically controlled surgery.  the patient tolerated the procedure well without any complication.  after discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.",7
"procedure performed: , inguinal herniorrhaphy.,procedure: , after informed consent was obtained, the patient was 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.,a standard inguinal incision was made and dissection was carried down to the external oblique aponeurosis using a combination of metzenbaum scissors and bovie electrocautery.  the external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  the external oblique was then incised with a scalpel, and this incision was carried out to the external ring using metzenbaum scissors.  having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a penrose drain was placed around the cord structures at the level of the pubic tubercle.  this penrose drain was then used to retract the cord structures as needed.  adherent cremasteric muscle was dissected free from the cord using bovie electrocautery.,the cord was then explored using a combination of sharp and blunt dissection, and the sac was found anteromedially to the cord structures.  the sac was dissected free from the cord structures using a combination of blunt dissection and bovie electrocautery.  once preperitoneal fat was encountered, the dissection stopped and the sac was suture ligated at the level of the preperitoneal fat using a 2-0 silk suture ligature.  the sac was excised and went to  pathology.  the ends of the suture were then cut and the stump retracted back into the abdomen.,the penrose drain was removed.  the wound was then irrigated using sterile saline, and hemostasis was obtained using bovie electrocautery.  the incision in the external oblique was approximated using a 3-0 vicryl in a running fashion, thus reforming the external ring.  the skin incision was approximated with 4-0 vicryl in a subcuticular fashion.  the skin was prepped and draped with benzoin, and steri-strips were applied.  a dressing consisting of a 2 x 2 and opsite was then applied.  all surgical counts were reported as correct.,having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.",36
"preoperative diagnosis: ,open angle glaucoma ox,postoperative diagnosis:, open angle glaucoma ox,procedure:, ahmed valve model s2 implant with pericardial reinforcement xxx eye,indications: ,this is a xx-year-old (wo)man with glaucoma in the ox eye, uncontrolled by maximum tolerated medical therapy.,procedure: ,the risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. informed consent was obtained. patient received several sets of drops in his/her xxx eye including ocuflox and ocular. (s)he was taken to the operating room where monitored anesthetic care was initiated. retrobulbar anesthesia was then administered to the xxx eye using a 50:50 mixture of 2% plain lidocaine and 0.05% marcaine. the xxx eye was then prepped and draped in the usual sterile ophthalmic fashion. a speculum was placed on the eyelids and microscope was brought into position. a #7-0 vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. at this point, smooth forceps and westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. this was then dissected anteriorly to the limbus edge and then posteriorly. steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. at this point, we primed the ahmed valve with a #27 gauge cannula using bss and it was noted to be patent. we then placed ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. we then measured with calipers so that it was positioned 9 mm posterior to the limbus. the ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. we then applied light cautery to the superotemporal episcleral bed. we placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of healon. we then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. we then trimmed the tube, beveled up in a 30 degree fashion with vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. we burped some of the healon out of the anterior chamber and filled it with bss and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. we then tacked down the tubes to the sclera with #8-0 vicryl suture in a figure-of- eight fashion. the pericardium was soaked in gentamicin. we then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. at this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 vicryl suture on a tg needle in a running fashion with interrupted locking bites. we then removed the traction suture. at the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. the remaining portion of the healon was burped out of the anterior chamber with bss and the pressure was felt to be adequate. the speculum was removed. ocuflox and maxitrol ointment were placed over the eye. then, an eye patch and shield were placed over the eye. the patient was awakened and taken to the recovery room in stable condition.",24
"subjective:,  this is a 1-month-old who comes in for a healthy checkup.  mom says things are gone very well.  he is kind of acting like he has got a little bit of sore throat but no fevers.  he is still eating well.  he is up to 4 ounces every feeding.  he has not been spitting up.  voiding and stooling well.,past medical history:,  reviewed, very healthy.,current medications:,  none.,allergies to medicines:,  none.,dietary: , his formula fed on enfamil lipil.  voiding and stooling well.  growth chart reviewed with mom.,developmental:,  he is starting to track with his eyes.  he is smiling a little bit, moving hands and feet symmetrically.,physical examination:,  in general well-developed, well-nourished male in no acute distress.,dermatologic:  without rash or lesion.,heent:  head normocephalic and atraumatic.  anterior fontanel soft and flat.  eyes:  pupils equal, round and reactive to light.  extraocular movements intact.  red reflexes present bilaterally.  does appear to have conjugate gaze.  ears:  tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  nares are patent, pink mucosa, moist.  oropharynx clear with pink mucosa, normal moisture.,neck:  supple without masses.,chest:  clear to auscultation and percussion with easy respirations and no accessory muscle use.,cardiovascular:  regular rate and rhythm without murmurs, rubs, heaves or gallops.,abdomen:  soft, nontender, nondistended without hepatosplenomegaly.,gu exam:  normal tanner i male.  testes descended bilaterally.  no hernias noted.,extremities:  pink and warm.  moving all extremities well.  no subluxation of the hips and leg creases appear symmetric.,neurologic:  alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  fixes and follows appropriately to both voice and face.,assessment:,  well child check.,plan:,1.  diet, growth and safety discussed.,2.  immunizations discussed and updated with hepatitis b.,3.  return to clinic at two months of age.  call if problems.",27
"procedures performed: , c5-c6 anterior cervical discectomy, allograft fusion, and anterior plating.,estimated blood loss: , 10 ml.,clinical note: , this is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  we decided go ahead with anterior cervical discectomy at c5-c6 and fusion.  the risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,description of procedure:  ,the patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  the patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  he had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  the tape was placed and his arms were well padded.  he was prepped and draped in a sterile fashion.  a linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  we separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  we then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  we placed caspar retractors for medial and lateral exposure over the c5-c6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  we then marked the disc space.  we then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  we then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  we took down posterior longitudinal ligament as well.  we incised the 6-mm cornerstone bone.  we placed a 6-mm parallel medium bone nicely into the disc space.  we then sized a 23-mm plate.  we inserted the screws nicely above and below.  we tightened down the lock-nuts.  we irrigated the wound.  we assured hemostasis using bone wax prior to placing the plate.  we then assured hemostasis once again.  we reapproximated the platysma using 3-0 vicryl in a simple interrupted fashion.  the subcutaneous level was closed using 3-0 vicryl in a simple buried fashion.  the skin was closed with 3-0 monocryl in a running subcuticular stitch.  steri-strips were applied.  dry sterile dressing with telfa was applied over this.  we obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  i was present as a primary surgeon throughout the entire case.",21
"preoperative diagnosis: , inguinal hernia.,postoperative diagnosis: , direct inguinal hernia.,procedure performed:,  rutkow direct inguinal herniorrhaphy.,anesthesia: , general endotracheal.,description of procedure:  ,after informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  general endotracheal anesthesia was induced without incident.  preoperative antibiotics were given for prophylaxis against surgical infection.  the patient was prepped and draped in the usual sterile fashion.,a standard inguinal incision was made, and dissection was carried down to the external oblique aponeurosis using a combination of metzenbaum scissors and bovie electrocautery.  the external oblique aponeurosis was cleared of overlying adherent tissue, and the external ring was delineated.  the external oblique was then incised with a scalpel and this incision was carried out to the external ring using metzenbaum scissors.  having exposed the inguinal canal, the cord structures were separated from the canal using blunt dissection, and a penrose drain was placed around the cord structures at the level of the pubic tubercle.  this penrose drain was then used to retract the cord structures as needed.  adherent cremasteric muscle was dissected free from the cord using bovie electrocautery.,the cord was then explored using a combination of sharp and blunt dissection, and no sac was found.  the hernia was found coming from the floor of the inguinal canal medial to the inferior epigastric vessels.  this was dissected back to the hernia opening.  the hernia was inverted back into the abdominal cavity and a large perfix plug inserted into the ring.  the plug was secured to the ring by interrupted 2-0 prolene sutures.,the perfix onlay patch was then placed on the floor of the inguinal canal and secured in place using interrupted 2-0 prolene sutures.  by reinforcing the floor with the onlay patch, a new internal ring was thus formed.,the penrose drain was removed.  the wound was then irrigated using sterile saline, and hemostasis was obtained using bovie electrocautery.  the incision in the external oblique was approximated using a 2-0 vicryl in a running fashion, thus reforming the external ring.  the skin incision was approximated with 4-0 monocryl in a subcuticular fashion.  the skin was prepped with benzoin, and steri-strips were 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.",36
"subjective:,  patient presents with mom for first visit to the office for two week well-child check.  mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  nursing every two to three hours with normal voiding and stooling pattern.  she does have a little bit of some gas and mom has been using mylicon drops which are helpful.  she is burping well, hiccuping, sneezing and burping appropriately.  growth and development:  denver ii normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  see denver ii form in the chart.,past medical history:,  mom reports uncomplicated pregnancy and delivery with prenatal care provided by dr. hoing.  delivery at newton medical center at 39 weeks, 5 days gestation.  birth weight was 3160 g.  length 49.5 cm.  head circumference 33 cm.  infant was delivered to 22-year-old a-positive mom who is g1 p0, now p1.  infant did well after delivery and was dismissed to home with mom the following day.  no other hospitalizations.  no surgeries.,allergies: , none.,medications:,  gas drops p.r.n.,family history: , significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  history of cancer and asthma on the paternal side of the family.  mom unsure of what type of cancer.,social history:,  patient lives at home with 22-year-old mother aubrey mizel and her parents bud and sue mizel in newton, kansas.  father of the baby, shivanka silva age 30, is a full-time student at wsu in wichita, kansas and does help with care of the newborn.  there is no smoking in the home.  family does have one pet dog in home.,review of systems:,  as per hpi; otherwise negative.,objective:,vital signs:  weight 7 pounds, 1-1/5 ounces.  height 21 inches.  head circumference 35.8 cm.  temperature 97.7.,general:  well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,heent:  atraumatic, normocephalic.  anterior fontanel soft and flat.  pupils equal, round and reactive.  sclerae clear.  red reflex present bilaterally.  tms clear bilaterally.  oropharynx:  mucous membranes moist and pink.,neck:  supple, no lymphadenopathy.,chest:  clear to auscultation bilaterally.  no wheeze or crackles.  good air exchange.,cardiovascular:  regular rate and rhythm.  no murmur.  good pulses bilaterally.,abdomen:  soft, nontender.  nondistended.  positive bowel sounds.  no masses or organomegaly.  healing umbilicus.,gu:  tanner i female genitalia.  femoral pulses equal bilaterally.  no rash.,extremities:  full range of motion.  no cyanosis, clubbing or edema.  negative ortolani and barlow maneuver.,back:  straight.  no scoliosis.  some increased pigment over the sacrum.,integument:  warm, dry and pink without lesions.,neurological:  alert.  good muscle tone and strength.,assessment/plan:,1. well 2-week-old mixed race caucasian and middle eastern descent female.,2. anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  gave two week well-child check handout to mom.  plan follow up for the one month well-child check or as needed for acute care.  mom will call for feeding problems, breathing problems or fever.  otherwise, plan to see at one month.",27
"preoperative diagnoses,1.  surgical absence of left nipple areola with personal history of breast cancer.,2.  breast asymmetry.,postoperative diagnoses,1.  surgical absence of left nipple areola with personal history of breast cancer.,2.  breast asymmetry.,procedure,1.  left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  redo right mastopexy.,anesthesia,general endotracheal.,complications,none.,description of procedure in detail,the patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  the initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  this was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  the defect was then closed with 3-0 vicryl followed by 3-0 chromic suture in a running locked fashion.  the area was dressed with antibiotic ointment and then a peri-pad.  the patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,a maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  at this point, a bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  when this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  at this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  at this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  the areolar skin graft was pie crusted.  then, at this point, the area of areola was dressed with silicone gel sheeting.  a silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  mastisol and steri-strips were then applied.,at this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  the skin was removed from the area and then a layered closure of 3-0 vicryl followed by 3-0 pds in a running subcuticular fashion was carried out.  when this had been completed, the mastisol and steri-strips were applied to the transverse right breast incision.  fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  the patient was then placed in surgi-bra and then was taken from the operating room to the recovery room in good condition.",36
"reason for exam:,  cva.,indications: , cva.,this is technically acceptable.  there is some limitation related to body habitus.,dimensions:  ,the interventricular septum 1.2, posterior wall 10.9, left ventricular end-diastolic 5.5, and end-systolic 4.5, the left atrium 3.9.,findings: , the left atrium was mildly dilated.  no masses or thrombi were seen.  the left ventricle showed borderline left ventricular hypertrophy with normal wall motion and wall thickening, ef of 60%.  the right atrium and right ventricle are normal in size.,mitral valve showed mitral annular calcification in the posterior aspect of the valve.  the valve itself was structurally normal.  no vegetations seen.  no significant mr. mitral inflow pattern was consistent with diastolic dysfunction grade 1.  the aortic valve showed minimal thickening with good exposure and coaptation.  peak velocity is normal.  no ai.,pulmonic and tricuspid valves were both structurally normal.,interatrial septum was appeared to be intact in the views obtained.  a bubble study was not performed.,no pericardial effusion was seen.  aortic arch was not assessed.,conclusions:,1.  borderline left ventricular hypertrophy with normal ejection fraction at 60%.,2.  mitral annular calcification with structurally normal mitral valve.,3.  no intracavitary thrombi is seen.,4.  interatrial septum was somewhat difficult to assess, but appeared to be intact on the views obtained.",31
"preoperative diagnosis: , recurrent dysplasia of vulva.,postoperative diagnosis:,  same.,operation performed:,  carbon dioxide laser photo-ablation.,anesthesia: , general, laryngeal mask.,indications for procedure: , the patient has a past history of recurrent vulvar dysplasia.  she has had multiple prior procedures for treatment.  she was counseled to undergo laser photo-ablation.,findings:,  examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions.  after staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,procedure:  ,the patient was brought to the operating room with an iv in place.  anesthetic was administered, after which she was placed in the lithotomy position.  examination under anesthesia was performed, after which she was prepped and draped.  acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion.  the carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined reid.  setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode.  excellent hemostasis was noted and bacitracin was applied prophylactically.  the patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.",36
"preoperative diagnosis: , lumbar stenosis.,postoperative diagnoses:,  lumbar stenosis and cerebrospinal fluid fistula.,title of the operation,1.  lumbar laminectomy for decompression with foraminotomies l3-l4, l4-l5, l5-s1 microtechniques.,2.  repair of csf fistula, microtechniques l5-s1, application of duraseal.,indications:,  the patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  she was evaluated with an mri scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at c4-c5, c5-c6, and c6-c7 as well as a complete block of the contrast at l4-l5 and no contrast at l5-s1 either and stenosis at l3-l4 and all the way up, but worse at l3-l4, l4-l5, and l5-s1.  yesterday, she underwent an anterior cervical discectomy and fusions c4-c5, c5-c6, c6-c7 and had some improvement of her symptoms and increased strength, even in the recovery room.  she was kept in the icu because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  the rationale for putting the surgery is close together that she is normally on coumadin for atrial fibrillation, though she has been cardioverted.  she and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,procedure: , the patient was brought from the neuro icu to the operating room, where general endotracheal anesthesia was obtained.  she was rolled in a prone position on the wilson frame.  the back was prepared in the usual manner with betadine soak, followed by betadine paint.  markings were applied.  sterile drapes were applied.  using the usual anatomical landmarks, linear midline incision was made presumed over l4-l5 and l5-s1.  sharp dissection was carried down into subcutaneous tissue, then bovie electrocautery was used to isolate the spinous processes.  a kocher clamp was placed in the anterior spinous ligament and this turned out to be l5-s1.  the incision was extended rostrally and deep gelpi's were inserted to expose the spinous processes and lamina of l3, l4, l5, and s1.  using the leksell rongeur, the spinous processes of l4 and l5 were removed completely, and the caudal part of l3.  a high-speed drill was then used to thin the caudal lamina of l3, all of the lamina of l4 and of l5.  then using various kerrison punches, i proceeded to perform a laminectomy.  removing the l5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  there was csf leak.  the lamina removal was continued, ligamentum flavum was removed to expose all the dura.  then using 4-0 nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  there was no csf leak with valsalva.,i then continued the laminectomy removing all of the lamina of l5 and of l4, removing the ligamentum flavum between l3-l4, l4-l5 and l5-s1.  foraminotomies were accomplished bilaterally.  the caudal aspect of the lamina of l3 also was removed.  the dura came up quite nicely.  i explored out along the l4, l5, and s1 nerve roots after completing the foraminotomies, the roots were quite free.  further more, the thecal sac came up quite nicely.  in order to ensure no csf leak, we would follow the patient out of the operating room.  the dural closure was covered with a small piece of fat.  this was all then covered with duraseal glue.  gelfoam was placed on top of this, then the muscle was closed with interrupted 0 ethibond.  the lumbodorsal fascia was closed with multiple sutures of interrupted 0 ethibond in a watertight fashion.  scarpa's fascia was closed with a running 0 vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  the wound was blocked with 0.5% plain marcaine.,estimated blood loss:  estimated blood loss for the case was about 100 ml.,sponge and needle counts:  correct.,findings:  a very tight high-grade stenosis at l3-l4, l4-l5, and l5-s1.  there were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,the patient tolerated the procedure well with stable vitals throughout.",21
"exam: , single frontal view of the chest.,history: , atelectasis.  patient is status-post surgical correction for asd.,technique: , a single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,findings:,  current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  sternotomy wires are noted.  they appear in appropriate placement.  there are no focal areas of consolidation to suggest pneumonia.  once again seen is minimal amount of bilateral basilar atelectasis.  the cardiomediastinal silhouette appears to be within normal limits at this time.  no evidence of any pneumothoraces or pleural effusions.,impression:,1.  there has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique.",2
"preoperative diagnoses:,1.  carotid artery occlusive disease.,2.  peripheral vascular disease.,postoperative diagnoses:,1.  carotid artery occlusive disease.,2.  peripheral vascular disease.,operations performed:,1.  bilateral carotid cerebral angiogram.,2.  right femoral-popliteal angiogram.,findings: , the right carotid cerebral system was selectively catheterized and visualized.  the right internal carotid artery was found to be very tortuous with kinking in its cervical portions, but no focal stenosis was noted.  likewise, the intracranial portion of the right internal carotid artery showed no significant disease nor did the right middle cerebral artery.,the left carotid cerebral system was selectively catheterized and visualized.  the cervical portion of the left internal carotid artery showed a 30 to 40% stenosis with small ulcer crater present.  the intracranial portion of the left internal carotid artery showed no significant disease nor did the left middle cerebral artery.,visualization of the right lower extremity showed no significant disease.,procedure: , with the patient in supine position under local anesthesia plus intravenous sedation, the groin areas were prepped and draped in a sterile fashion.,the common femoral artery was punctured in a routine retrograde fashion and a 5-french introducer sheath was advanced under fluoroscopic guidance.  a catheter was then placed in the aortic arch and the right and left common carotid arteries were then selectively catheterized and visualized as described above.,following completion of the above, the catheter and introducer sheath were removed.  heparin had been initially given, which was reversed with protamine.  firm pressure was held over the puncture site for 20 minutes, followed by application of a sterile coverlet dressing and sandbag compression.,the patient tolerated the procedure well throughout.",2
"admitting diagnosis:,  posttraumatic av in right femoral head.,discharge diagnosis:,  posttraumatic av in right femoral head.,secondary diagnoses prior to hospitalization:,1.  opioid use.,2.  right hip surgery.,3.  appendectomy.,4.  gastroesophageal reflux disease.,5.  hepatitis diagnosed by liver biopsy.,6.  blood transfusion.,6.  smoker.,7.  trauma with multiple orthopedic procedures.,8.  hip arthroscopy.,postop comorbidities: , postop acute blood loss anemia requiring transfusion and postop pain.,procedures during this hospitalization:,  right total hip arthroplasty and removal of hardware.,consults:,  acute pain team consult.,disposition: , home.,history of present illness and hospital course:,  for details, please refer to clinic notes and op notes.  in brief, the patient is a 47-year-old female with a posttraumatic av in the right femoral head.  she came in consult with dr. x who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  after being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  she was then transferred to pacu for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  dvt prophylaxis was initiated with lovenox.  postop pain was adequately managed with the aid of acute pain team.  postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,disposition:,  home.  on the day of her discharge, she was afebrile, vital signs were stable.  she was in no acute distress.  her right hip incision was clean, dry, and intact.  extremity was warm and well perfused.  compartments were soft.  capillary refill less than two seconds.  distal pulses were present.,predischarge laboratory findings: , white count of 10.9, hemoglobin of 9.5, and bmp is pending.,discharge instructions: , continue diet as before.,activity: , weightbearing as tolerated in the right lower extremity as instructed.  do not lift, drive, move furniture, do strenuous activity for six weeks.  call dr. x if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,follow-up appointment:  follow up with dr. x in two weeks.",9
"reason for admission: , rectal bleeding.,history of present illness:  ,the patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  he states that he had some stomach discomfort in the last 4 weeks.  he has had some physical therapy for his lower back secondary to pain after hernia repair.  he states that the pain worsened after this.  he has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  he denies any dysuria.  he denies any hematemesis.  he denies any pleuritic chest pain.  he denies any hemoptysis.,past medical history:,1.  history of bilateral hernia repair by dr. x in 8/2008.,2.  history of rectal bleeding.,allergies: , none.,medications:,1.  cipro.,2.  lomotil.,family history: , noncontributory.,social history: , no tobacco, alcohol or iv drug use.,review of systems: , as per the history of present illness otherwise unremarkable.,physical examination:,vital signs:  the patient is afebrile.  pulse 117, respirations 18, and blood pressure 117/55.  saturating 98% on room air.,general:  the patient is alert and oriented x3.,heent:  pupils are equal, round, and reactive to light and accommodation.  extraocular movements are intact.  oropharynx is clear without exudates.,neck:  supple.  no thyromegaly.  no jugular venous distention.,heart:  tachycardic.  regular rhythm without murmurs, rubs or gallops.,lungs:  clear to auscultation bilaterally both anteriorly and posteriorly.,abdomen:  positive bowel sounds.  soft and nontender with no guarding.,extremities:  no clubbing, cyanosis or edema in the upper or lower extremities.,neurologic:  nonfocal.,laboratory studies:,  sodium 131, potassium 3.9, chloride 94, co2 25, bun 15, creatinine 0.9, glucose 124, inr 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  ekg shows sinus tachycardia.,problem list:,1.  colitis.,2.  sepsis.,3.  rectal bleeding.,recommendations:,1.  gi consult with dr. y's group.,2.  continue levaquin and flagyl.,3.  iv fluids.,4.  send for fecal wbcs, o&p, and c. diff.,5.  ct of the abdomen and pelvis to rule out abdominal pathology.,6.  ppi for pud prophylaxis.",13
"specimens:,1.  pelvis-right pelvic obturator node.,2.  pelvis-left pelvic obturator node.,3.  prostate.,post-operative diagnosis: , adenocarcinoma of prostate, erectile dysfunction.,diagnostic opinion:,1.  adenocarcinoma, gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  no evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  metastatic adenocarcinoma, left obturator lymph node; see description.,clinical history: , none listed.,gross description:,specimen #1 labeled ""right pelvic obturator lymph nodes"" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  there are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  the entire specimen is cut into several portions and totally embedded.,specimen #2 labeled ""left pelvic obturation lymph nodes"" consists of an adipose tissue measuring 4 x 2 x 1 cm.  there are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  the entire specimen is cut into 1 cm.  the entire specimen is cut into several portions and totally embedded.,specimen #3 labeled ""prostate"" consists of a prostate.  it measures 5 x 4.5 x 4 cm.  the external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  external surface also shows tumor induration especially in right side.  external surface is stained with green ink.  the cut surface shows diffuse tumor induration especially in right side.  the tumor appears to extend to excision margin.  multiple representative sections are made.,microscopic description:,section #1 reveals lymph node.  there is no evidence of metastatic carcinoma.,section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,section #3 reveals adenocarcinoma of prostate.  gleason's score 9 (5+4).  the tumor shows extension to periprostatic tissue as well as margin involvement.  seminal vesicle attached to prostate tissue shows tumor invasion.  dr. xxx reviewed the above case.  his opinion agrees with the above diagnosis.,summary:,a.  adenocarcinoma of prostate, gleason's score 9, with both lobe involvement and seminal vesicle involvement (t3b).,b.  there is lymph node metastasis (n1).,c.  distant metastasis cannot be assessed (mx).,d.  excision margin is positive and there is tumor extension to periprostatic tissue.",17
"preoperative diagnosis: , right temporal lobe intracerebral hemorrhage.,postoperative diagnoses:,1.  right temporal lobe intracerebral hemorrhage.,2.  possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,procedures:,1.  emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  biopsy of dura.,3.  microscopic dissection using intraoperative microscope.,specimens: , temporal lobe lesion and dura as well as specimen for microbiology for culture.,drains:,  medium hemovac drain.,findings: , vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,anesthesia: , general.,estimated blood loss: , per anesthesia.,fluids: , one unit of packed red blood cells given intraoperatively.,the patient was brought to the operating room emergently.  this is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,the patient apparently became hemiplegic suddenly today.  she also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,she was brought to emergency room where a ct of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  there is significant mass effect.  there is mixed density in the parenchyma of the temporal lobe.,she was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  however, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ich as well as biopsy of the temporal lobe as well as the dura.,procedure in detail: , the patient was anesthetized by the anesthesiology team.  appropriate central line as well as arterial line, foley catheter, ted, and scds were placed.  the patient was positioned supine with a three-point mayfield head pin holder.  her scalp was prepped and draped in a sterile manner.  her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  the scalp was resected anteriorly.  the subdural scar was noted, and hemostasis was achieved using bovie cautery.  the temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,the titanium plating system was then removed in its entirety.  the bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,the granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as bovie cautery.,the bone flap was then removed using leksell rongeur, and the underlying dura was inspected.  it was quite full.  the 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with leksell rongeur.  the sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,hemostasis was achieved on the fresh bony edges using bone wax.  the dura pack-up stitches were noted around the periphery from the previous craniotomy.  this was left in place.,the microscope was then brought in to use for the remainder of the procedure until closure.  using a #15 blade, a new durotomy was then made.  then, the durotomy was carried out using metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  the underlying brain was quite edematous.,along the temporal lobe there was a stain of xanthochromia along the surface.  thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  the parenchyma of the brain did not appear normal.  it was quite vascular.  furthermore, there was a hematoma mixed in with the brain itself.  thus a core biopsy was then performed in the temporal tip.  the overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  furthermore, sample of the temporal lobe was cultured.,hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  no attempt was made to enter into the sylvian fissure.  once hemostasis was meticulously achieved, the brain was inspected.  it still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  however, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  duragen was then used for duraplasty because of the resected dura.  the bone flap was then repositioned using lorenz plating system.  then a medium hemovac drain was placed in subdural space.  temporalis muscle was approximated using 2-0 vicryl.  the galea was then reapproximated using inverted 2-0 vicryl.  the scalp was then reapproximated using staples.  the head was then dressed and wrapped in a sterile fashion.,she was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  the pupils are 3 mm bilaterally reactive to light.  i accompanied her and transported her to the icu where i signed out to the icu attending.",36
"procedure performed: , egd with biopsy.,indication: , mrs. abc is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  she was admitted because of recurrent nausea and vomiting, with displacement of the gej feeding tube.  a ct scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  the endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,medications: , fentanyl 25 mcg, versed 2 mg, 2% lidocaine spray to the pharynx.,instrument: , gif 160.,procedure report:,  informed consent was obtained from mrs. abc's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  consent was not obtained from mrs. morales due to her recent narcotic administration.  conscious sedation was achieved with the patient lying in the left lateral decubitus position.  the endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,findings:,1.  esophagus:  there was evidence of grade c esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  multiple biopsies were obtained from this region and placed in jar #1.,2.  stomach:  small hiatal hernia was noted within the cardia of the stomach.  there was an indentation/scar from the placement of the previous peg tube and there was suture material noted within the body and antrum of the stomach.  the remainder of the stomach examination was normal.  there was no feeding tube remnant seen within the stomach.,3.  duodenum:  this was normal.,complications:,  none.,assessment:,1.  grade c esophagitis seen within the distal, mid, and proximal esophagus.,2.  small hiatal hernia.,3.  evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,plan: , followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.",13
"subjective:,  he is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  he has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by dr. blackman; it looked like it was depo-medrol 80 mg.  he said that it worked fairly well, although it seemed to still take awhile to get rid of it.  he has been using over-the-counter benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,objective:,vitals:  temperature is 99.2.  his weight is 207 pounds.,skin:  examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,assessment and ,plan:,  poison ivy.  plan would be solu-medrol 125 mg im x 1.  continue over-the-counter benadryl or rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter benadryl if he would like to use that instead.",33
"preoperative diagnosis:, chronic abdominal pain and heme positive stool.,postoperative diagnoses:,1.  antral gastritis.,2.  duodenal polyp.,procedure performed:,  esophagogastroduodenoscopy with photos and antral biopsy.,anesthesia: , demerol and versed.,description of procedure: , consent was obtained after all risks and benefits were described.  the patient was brought back into the endoscopy suite.  the aforementioned anesthesia was given.  once the patient was properly anesthetized, bite block was placed in the patient's mouth.  then, the patient was given the aforementioned anesthesia.  once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  the air was insufflated down.  the scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  the scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  the scope was pulled back into the stomach in order to flex upon itself and straightened out.  biopsies were taken for clo and histology of the antrum.  the scope was pulled back.  the junction was visualized.  no other masses or lesions were seen.  the scope was removed.  the patient tolerated the procedure well.  we will recommend the patient be on some type of a h2 blocker.  further recommendations to follow.",36
"preoperative diagnosis:  ,lateral epicondylitis.",25
"history of present illness: , the patient is a 45-year-old male complaining of abdominal pain.  the patient also has a long-standing history of diabetes which is treated with micronase daily.,past medical history: , there is no significant past medical history noted today.,physical examination:,heent:  patient denies ear abnormalities, nose abnormalities and throat abnormalities.,cardio:  patient has history of elevated cholesterol, but does not have ashd, hypertension and pvd.,resp:  patient denies asthma, lung infections and lung lesions.,gi:  patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,gu:  patient has history of urinary tract disorder, but does not have bladder disorder and kidney disorder.,endocrine:  patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,dermatology:  patient denies allergic reactions, rashes and skin lesions.,meds:,  micronase 2.5 mg tab po qam #30.  bactrim 400/80 tab po bid #30.,social history:,  no known history of drug or alcohol abuse.  work, diet, and exercise patterns are within normal limits.,family history:,  no significant family history.,review of systems:,  non-contributory.,vital signs:  height = 72 in.  weight =184 lbs.  upright bp = 120/80 mmhg.  pulse = 80 bpm.  resp =12 pm.  patient is afebrile.,neck:  the neck is supple.  there is no jugular venous distension.  the thyroid is nontender, or normal size and conto.,lungs:  lung expansion and excursions are symmetric.  the lungs are clear to auscultation and percussion.,cardio:  there is a regular rhythm.  si and s2 are normal.  no abnormal heart sounds are detected.  blood pressure is equal bilaterally.,abdomen:  normal bowel sounds are present.  the abdomen is soft; the abdomen is nontender; without organomegaly; there is no cva tenderness.  no hernias are noted.,extremities:  there is no clubbing, cyanosis, or edema.,assessment: , diabetes type ii uncontrolled.  acute cystitis.,plan: , endocrinology consult, complete cbc.  ,rx: , micronase 2.5 mg tab po qam #30, bactrim 400/80 tab po bid #30.",14
"procedures performed:,1.  functional endoscopic sinus surgery.,2.  bilateral maxillary antrostomy.,3.  bilateral total ethmoidectomy.,4.  bilateral nasal polypectomy.,5.  right middle turbinate reduction.,anesthesia:,  general endotracheal tube.,blood loss:,  approximately 50 cc.,indication: , this is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  she has underwent sinus surgery in the past approximately 12 years ago with the ct evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,procedure:  ,after all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  the patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the department of anesthesia.  the patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  the nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  the patient was then prepped and draped in the usual fashion.,attention was directed first to the left nasal cavity.  a zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  the initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  there was also polypoid disease present within the left middle meatus.  nasopharynx was visualized with a patent eustachian tube.  at this point, the xps micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  the ostium to the sphenoid sinus was visualized and was not entered.  at this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  a ball-tip probe was then used to localize the openings for the natural maxillary ostium.  side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  the opening of the maxillary sinus was visualized.  the posterior fontanelle was taken down with the use of straight line forceps.  it should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  the maxillary sinus ostia was then suctioned with olive-tip suction and maxillary wash was performed.  the remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  the basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  all polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  attention was then directed to the right nasal cavity.  again, a sinus endoscope was inserted.  inspection revealed a grossly hypertrophied turbinate.  it was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the takahashi forceps.  sinus endoscope was then inserted all the way down through the nasopharynx.  again, the eustachian tube was visualized without any obstructing lesions or masses.  upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  the ball-tip probe was again used to locate the right maxillary ostium.  the side-biting forceps was used further take down the uncinate process.  the maxillary ostium was then widened with use of a xps microdebrider.  a maxillary sinus wash was then performed.  now, the attention was directed to the ethmoid air cells.  it should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  this was again taken down with the use of xps microdebrider while the surgical assistant carefully palpated the patient's eye.,once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  once all bleeding has been controlled, all surgical instruments were removed and merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  at this point, the procedure was felt to be complete.  the patient was awakened and taken to the recovery room without incident.",10
"preoperative diagnosis:,  bilateral hydroceles.,postoperative diagnosis:,  bilateral hydroceles.,procedure: , bilateral scrotal hydrocelectomies, large for both, and 0.5% marcaine wound instillation, 30 ml given.,estimated blood loss: , less than 10 ml.,fluids received: , 800 ml.,tubes and drains: , a 0.25-inch penrose drains x4.,indications for operation:  ,the patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time.  finally, he has decided to have them get repaired.  plan is for surgical repair.,description of operation:  ,the patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped.  iv antibiotics were given.  ancef 1 g given.  a scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery.  electrocautery was used for hemostasis.  once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid.  there was moderate amount of scarring on the testis itself from the tunica vaginalis.  it was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a lord maneuver.  once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation.  a similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with lord maneuver similarly.  this testis also was normal but had moderate amount of scarring on the tunic vaginalis from this.  a similar drain was placed.  the testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 ml of 0.5% marcaine without epinephrine.  iv toradol was given at the end of the procedure.  the skin was then sutured with a running interlocking suture of 3-0 vicryl and the drains were sutured to place with 3-0 vicryl.  bacitracin dressing, abd dressing, and jock strap were placed.  the patient was in stable condition upon transfer to the recovery room.",36
"subjective:,  the patient states that he feels sick and weak.,physical examination:,vital signs:  highest temperature recorded over the past 24 hours was 101.1, and current temperature is 99.2.,general:  the patient looks tired.,heent:  oral mucosa is dry.,chest:  clear to auscultation.  he states that he has a mild cough, not productive.,cardiovascular:  first and second heart sounds were heard.  no murmur was appreciated.,abdomen:  soft and nontender.  bowel sounds are positive. murphy's sign is negative.,extremities:  there is no swelling.,neuro:  the patient is alert and oriented x 3.  examination is nonfocal.,laboratory data: , white count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000.  glucose is in the low 100s.  comprehensive metabolic panel is unremarkable.  ua is negative for infection.,assessment and plan:,1.  fever of undetermined origin, probably viral since white count is normal.  would continue current antibiotics empirically.,2.  dehydration.  hydrate the patient.,3.  prostatic hypertrophy.  urologist, dr. x.,4.  dvt prophylaxis with subcutaneous heparin.",33
"admitting diagnosis: , intractable migraine with aura.,discharge diagnosis:,  migraine with aura.,secondary diagnoses:,1.  bipolar disorder.,2.  iron deficiency anemia.,3.  anxiety disorder.,4.  history of tubal ligation.,procedures during this hospitalization:,1.  ct of the head with and without contrast, which was negative.,2.  an mra of the head and neck with and without contrast also negative.,3.  the cta of the neck also read as negative.,4.  the patient also underwent a lumbar puncture in the emergency department, which was grossly unremarkable though an opening pressure was not obtained.,home medications:,1.  vicodin 5/500 p.r.n.,2.  celexa 40 mg daily.,3.  phenergan 25 mg p.o. p.r.n.,4.  abilify 10 mg p.o. daily.,5.  klonopin 0.5 mg p.o. b.i.d.,6.  tramadol 30 mg p.r.n.,7.  ranitidine 150 mg p.o. b.i.d.,allergies:,  sulfa drugs.,history of present illness: , the patient is a 25-year-old right-handed caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the july 31, 2008.  she described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  the patient also perceived some swelling in her face.  once in the emergency department, the patient underwent a very thorough evaluation and examination.  she was given the migraine cocktail.  also was given morphine a total of 8 mg while in the emergency department.  for full details on the history of present illness, please see the previous history and physical.,brief summary of hospital course:  ,the patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  the patient was brought up to 4 or more early in the a.m. on the august 1, 2008 and was given the dihydroergotamine iv, which did allow some minimal resolution in her headache immediately.  at the time of examination this morning, the patient was feeling better and desired going home.  she states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,physical examination at the time of discharge: , general physical exam was unremarkable.  heent:  pupils were equal and respond to light and accommodation bilaterally.  extraocular movements were intact.  visual fields were intact to confrontation.  funduscopic exam revealed no disc pallor or edema.  retinal vasculature appeared normal.  face is symmetric.  facial sensation and strength are intact.  auditory acuities were grossly normal.  palate and uvula elevated symmetrically.  sternocleidomastoid and trapezius muscles are full strength bilaterally.  tongue protrudes in midline.  mental status exam: revealed the patient alert and oriented x 4.  speech was clear and language is normal.  fund of knowledge, memory, and attention are grossly intact.  neurologic exam:  vasomotor system revealed full power throughout.  normal muscle tone and bulk.  no pronator drift was appreciated.  coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  no tremor or dysmetria.  excellent sensory.  sensation is intact in all modalities throughout. the patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  gait was assessed, the patient's routine and tandem gait were normal.  the patient is able to balance on heels and toes.  romberg is negative.  reflexes are 2+ and symmetric throughout.  babinski reflexes are plantar.,disposition:,  the patient is discharged home.,instructions for followup:  ,the patient is to followup with her primary care physician as needed.",9
"cc:, intermittent binocular horizontal, vertical, and torsional diplopia.,hx: ,70y/o rhm referred by neuro-ophthalmology for evaluation of neuromuscular disease. in 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. an mri brain scan at that time was unremarkable. he was seen at uihc strabismus clinic in 5/93 for these symptoms. on exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. this was felt to possibly represent grave's disease. thyroid function studies were unremarkable, but orbital echography suggested graves orbitopathy. the patient was then seen in the neuro-ophthalmology clinic on 12/23/92. his exam remained unchanged. he underwent tensilon testing which was unremarkable. on 1/13/93, he was seen again in neuro-ophthalmology. his exam remained relatively unchanged and repeat tensilon testing was unremarkable. he then underwent a partial superior rectus resection, od, with only mild improvement of his diplopia. during his 8/27/96 neuro-ophthalmology clinic visit he was noted to have hypertropia od with left pseudogaze palsy and a right ptosis. the ptosis improved upon administration of tensilon and he was placed on mestinon 30mg tid. his diplopia subsequently improved, but did not resolve. the dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. at present he denied any fatigue on repetitive movement. he denied dysphagia, sob, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,meds: , viokase, probenecid, mestinon 30mg tid.,pmh:, 1) gastric ulcer 30 years ago, 2) cholecystectomy, 3) pancreatic insufficiency, 4) gout, 5) diplopia.,fhx:, mother died age 89 of ""old age."" father died age 89 of stroke. brother, age 74 with cad, sister died age 30 of cancer.,shx:, retired insurance salesman and denies history of tobacco or illicit drug us. he has no h/o etoh abuse and does not drink at present.,exam: ,bp 155/104.  hr 92. rr 12.  temp 34.6c. wt 76.2kg.,ms: unremarkable. normal speech with no dysarthria.,cn: right hypertropia (worse on rightward gaze and less on leftward gaze). minimal to no ptosis, od. no ptosis, os. vfftc. no complaint of diplopia. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: no deficits appreciated on pp/vib/lt/prop/temp testing.,coordination/station/gait: unremarkable.,reflexes: 2/2 throughout. plantar responses were flexor on the right and withdrawal on the left.,heent and gen exam: unremarkable.,course:, emg/ncv, 9/26/96: repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. the patient had been off mestinon for 8 hours prior to testing. chest ct with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. this was highly suggestive of a thymoma. there were diffuse emphysematous disease with scarring in the lung bases. a few nodules suggestive of granulomas and few calcified perihilar lymph nodes. he underwent thoracotomy and resection of the mass. pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. acetylcholine receptor-binding antibody titer 12.8nmol/l (normal<0.7), acetylcholine receptor blocking antibody <10% (normal), acetylcholine receptor modulating antibody 42% (normal<19), striated muscle antibody 1:320 (normal<1:10). striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. he was subsequently treated with xrt and continued to complain of fatigue at his 4/18/97 oncology visit.",20
"preoperative diagnoses,1.  incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,postoperative diagnoses,1.  incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,operations performed,1.  robotic-assisted omentectomy.,2.  robotic-assisted pelvic lymph node dissection.,3.  attempted laparoscopy.,4.  exploratory laparotomy with bilateral pelvic bilateral periaortic lymph node dissection with multiple biopsies.,anesthesia:,  general/epidural anesthesia.,estimated blood loss:,  200 ml.,complications:,  none.,final sponge and needle counts: , correct, confirmed by x-ray jp drain x1.,indications for surgery: , mrs. a is a pleasant 66-year-old female who was diagnosed with an unsuspected grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary.  the patient is status post laparoscopic-assisted vaginal hysterectomy bso.  the patient was referred to me by dr. x.  because of the incomplete staging, the patient was advised to undergo a robotic-assisted surgical staging.  risks, benefits, and rationale of these procedures were reviewed.  the patient has understanding of these risks and wishes to proceed with the surgery as planned.,intraoperative findings,1.  no evidence of ascites.,2.  at the time of the exploratory laparotomy, the diaphragm was well palpated.  they were clear.  the low attachments were removed.  the lesser omentum was unremarkable.  the pancreas, spleen, and liver were unremarkable.  the gallbladder was unremarkable.  the stomach appeared grossly normal.  the small bowel was inspected from the ligament which starts to the ileocecal valve.  there is no evidence of disease.  paracolic gutter and peritoneum was free.  the omentum was grossly normal.,3.  in the pelvis, uterus, tubes, and ovaries were absent.  there was no evidence seeding along the bladder, pelvic, cul-de-sac, and peritoneum.,4.  retroperitoneally, pelvic lymph nodes were mostly normal; however, at the right aortic, there are nodes.  these nodes were extremely fibrotic and they were densely adherent to the anterior wall of the vena cava which precluded me from performing a robotic periaortic lymph node dissection.  there was some area that was suspicious right at the low right periaortic lymph node.  they were sent for frozen section and they came back as benign.  it is unclear to me why did the lymph nodes were quite fibrotic and firm, but we will wait for the pathology report.,procedure in detail: , the patient was given iv antibiotics prior to our incision site, sequential compression device was placed as part of the dvt prophylaxis.  i have requested an epidural catheter be placed for purpose of the periaortic lymph node dissection.  with this in mind, we proceeded as such.,we initially began with the robotic portion of the procedure.,a 1-cm supraumbilical incision made.  a veress needle was inserted without difficulty.  pneumoperitoneum was achieved to the abdominal pressure of 15 mmhg.  a 12mm trocar was inserted without difficulty.  after completion of this, a 12mm trocar was placed in the left lower quadrant 2 fingerbreadths medial to the anterior superior iliac spine under direct laparoscopic visualization.  after completion of this, a laparoscope was then placed in the left lower quadrant port to assist in the placement of the remainder of the da vinci ports.  two 8-mm ports were placed in the right upper quadrant 8 cm apart while one 8-mm port was placed in the left upper quadrant 8 cm apart.  after completion of this, the patient was placed in steep trendelenburg position.  the robotic system was then docked and after docking the robotic system, the instrumentation was inserted under direct laparoscopic visualization to ensure that there was no injury to the abdominal contents.  once this was completed, the robotic camera was then docked.  we then proceeded with our davinci portion of the procedure.,i then proceeded now with the omentectomy.  the omentum was taken off the transverse colon with the harmonic scalpel.  the entire omentum was removed and placed in the pelvis.  after completion of this, i then proceeded now with the pelvic lymph node dissection.,an incision was made parallel along the peritoneum overlying the psoas muscle.  all the lymph node bearing tissues along the external iliac artery and vein were subsequently skeletonized off the vessels and resected.  the lymph node bearing tissues interposed between the external iliac vein and psoas muscle were mobilized into the obturator fossa and subsequently removed off the accessory obturator vein, artery and nerve.  in the process of removing the lymphoid tissues, the genitofemoral nerve along with the accessory obturator vein, obturator artery and nerve were all preserved.  the lymphoid tissues interposed between the external iliac vein and psoas muscle along with the common iliac vessels were also subsequently removed.  the lymph node bearing tissues bifurcating at the hypogastric and the external iliac vein were likewise removed in addition to the hypogastric lymph nodes.  all the lymph node tissues were placed in an endobag and removed and submitted as pelvic nodes on the right side and subsequently the left side.  boundaries of the pelvic nodal dissection distally were the external circumflex iliac vein, laterally the psoas muscle along with the obturator internus fascia, medially the superior vesical artery along with the ureter, and inferiorly below the obturator nerve.,at this point in time, we have attempted the periaortic lymph node dissection.  i did open up the peritoneum overlying the bifurcation of the aorta.  this peritoneum was incised up to the level of the duodenal recess.  it was at this point in time that the periaortic lymph node dissection was extremely difficult.  i was unable to get a tissue plane as the lymph nodes were apparently very fibrotic.  i was concerned that i would tear off the anterior wall of the cava in the process of trying to perform the right periaortic lymph node.  for this reason, i aborted the robotic procedure or in after nearly attempting for about an hour and a half for the periaortic lymph nodes.  once this was unsuccessful, the robotic system was then dedocked.  i then placed additional ports.  a 5-mm port was placed in the suprapubic region, two fingerbreadths above.  a right lower quadrant 12-mm port was placed.  after completion of this, i had attempted to see whether we could do the remainder of the periaortic lymph node dissection via laparoscopically.  despite an attempt for a nearly 35 minutes, i was not able to get adequate exposure.  the small bowel kept on falling in the operative field which precluded us to perform the procedure safely.  for this reason, i converted to an open procedure.,a midline incision was made from suprapubic bone and extended above the umbilicus.  the abdominal cavity was entered without injuring the bell.  after entering the abdomen, omentum was removed.  ray-tec sponges were removed.  we covered for the ray-tec sponges.  after completion of this, thompson retractor was placed.  the patient was placed in c-trendelenburg position.  the bowel was packed cephalad.  retroperitoneum space was entered right and left ureters were identified.  i then meticulously resected the lymphoid-bearing tissues anterior and lateral to the cava.  this dissection was quite difficult as the lymph nodes were extremely fibrotic and adherent to the caval wall.  i was able to freed up these lymph nodes without injuring of the cava.  likewise, the left periaortic lymph node dissection was carried out from the level of the bifurcation to 1 cm above the ima.  all the periaortic lymph node dissection was then carried out.  after completion of this, i then took washings.  random biopsies were obtained of the cul-de-sac and right and left pelvic side wall along with the right and left paracolic gutter.  after completion of this, the patient appears to have tolerated the procedure well.  there was no obvious gross disease.  the bowel was inspected meticulously to ensure that there was no evidence of injury.  once this was completed, the bowel was placed back to its normal position.  several film solutions were placed.  we counted for sponges, needles, and instruments.  once this was counted for, the fascia was then closed with #2 vicryl suture in a mass closure fashion.  the subcutaneous route was copiously irrigated with water.  the jp drain was brought to the right lower quadrant incision.  all the incision ports were then closed with 3-0 monocryl suture.  likewise, the midline incision was closed with 3-0 monocryl sutures.,at the conclusion of the procedure, there was no obvious gross disease left.,",36
"admitting diagnoses:,  respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,history of presenting illness: , the baby is an ex-32 weeks small for gestational age infant with birth weight 1102.  baby was born at abcd hospital at 1333 on 07/14/2006.  mother is a 20-year-old gravida 1, para 0 female who received prenatal care.  prenatal course was complicated by low amniotic fluid index and hypertension.  she was evaluated for evolving preeclampsia and had a c-section secondary to the nonreassuring fetal status.  baby delivered operatively, apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to children's hospital.  infant was transferred to children's hospital for higher level of care, stayed at children's hospital for approximately 2 weeks, and was transferred back to abcd where he stayed until he was discharged on 08/16/2006.,hospital course: , at the time of transfer to abcd, these were the following issues.,feeding and nutrition: , baby was on tpn and p.o. feeds had been started and were advanced 1 ml q.6h.  baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention.  the p.o. feeds were held and iv d10 water was given.  baby was started on mylicon drops and glycerin suppositories.  abdominal ultrasound showed gaseous distention without signs of obstruction.  og tube was passed.  baby improved after couple of days when p.o. feedings were restarted.  baby was also given reglan.  at the time of discharge, baby was tolerating p.o. feeds well of bm fortified with 22-cal neosure.  feeding amounts at the time of discharge was between 35 to 50 ml per feed and weight was 1797 grams.,respirations: , at the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,hypoglycemia: , baby began to experience hypoglycemic episodes on 07/24/2006.  blood glucose level was as low as 46.  d10 was given initially as bolus.  baby continued to experience hypoglycemic episodes.  diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level.  the baby improved with diazoxide, hypoglycemic issues resolved and then began again.  diazoxide was discontinued, but the hypoglycemic issues restarted.  the diazoxide was restarted again.  blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued.  at the time of discharge, blood glucose levels were not being stable for 24 hours.,cardiovascular: , infant was hemodynamically stable on admission from madera.  infant has a closed pda.  infant had two cardiac echograms done.  the lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,cns:,  infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage.  the ultrasound was negative for intracranial hemorrhage.,infectious disease:,  the patient had been on antibiotics during the stay at madera.  at the time of admission to the abcd, the patient was not on any antibiotics and his clinically condition has remained stable.,hematology: , the patient is status post phototherapy at madera and was started on iron.,ophthalmology: ,  exam on 07/17/2006 showed immature retina.  the patient is to get followup exam after discharge.,discharge diagnosis: , stable ex-32-weeks preemie.,discharge instructions: , the patient has been educated on cpr measures.  followup appointment has been made at kid's care.  calcium challenge has been done.  the patient's parents are comfortable with feeding.  the patient has been discharged on neosure and expressed breast milk.,",9
"name of procedures,1.  selective coronary angiography.,2.  left heart catheterization.,3.  left ventriculography.,procedure in detail:  ,the right groin was sterilely prepped and draped in the usual fashion.  the area of the right coronary artery was anesthetized with 2% lidocaine and a 4-french sheath was placed.  conscious sedation was obtained using a combination of versed 1 mg and fentanyl 50 mcg.  a left #4, 4-french, judkins catheter was placed and advanced through the ostium of the left main coronary artery.  because of difficulty positioning the catheter, the catheter was removed and a 6-french sheath was placed and a 6-french #4 left judkins catheter was placed.  this was advanced through the ostium of the left main coronary artery where selective angiograms were performed.  following this, the 4-french right judkins catheter was placed and angiograms of the right coronary were performed.  a pigtail catheter was placed and a left heart catheterization was performed, followed by a left ventriculogram.  the left heart pullback was performed.  the catheter was removed and a small injection of contrast was given to the sheath.  the sheath was removed over a wire and an angio-seal was placed.  there were no complications.  total contrast media was 200 ml of optiray 350.  fluoroscopy time 5.3 minutes.  total x-ray dose is 1783 mgy.,hemodynamics:  ,rhythm is sinus throughout the procedure.  lv pressure of 155/22 mmhg, aortic pressure of 160/80 mmhg.  lv pullback demonstrates no gradient.,the right coronary artery is a nondominant vessel and free of disease.  this also gives rise to the conus branch and two rv free wall branches.  the left main has minor plaquing in the inferior aspect measuring no more than 10% to 15%.  this vessel then bifurcates into the lad and circumflex.  the circumflex is a large caliber vessel and is dominant.  this vessel gives rise to a large first marginal artery, a moderate sized second marginal branch, and additionally gives rise to a large third marginal artery and the pda.  there was a very eccentric and severe stenosis in the proximal circumflex measuring approximately 90% in severity.  the origin of the first marginal artery has a severe stenosis measuring approximately 90% in severity.  the distal circumflex has a 60% lesion just prior to the origin of the third marginal branch and pda.,the proximal lad is ectatic.  the lad gives rise to a large first diagonal artery that has a 90% lesion in its origin and a subtotal occlusion midway down the diagonal.  distal to the origin of this diagonal branch, there is another area of ectasia in the lad, followed by an area of stenosis that in some views is approximately 50% in severity.,the left ventriculogram demonstrates hypokinesis of the distal half of the inferior wall.  the overall ejection fraction is preserved.  there is moderate dilatation of the aortic root.  the calculated ejection fraction is 63%.,impression,1.  left ventricular dysfunction as evidenced by increased left ventricular end diastolic pressure and hypokinesis of the distal inferior wall.,2.  coronary artery disease with high-grade and complex lesion in the proximal portion of the dominant large circumflex coronary artery.  there is subtotal stenosis at the origin of the first obtuse marginal artery.,3.  a 60% stenosis in the distal circumflex.,4.  ectasia of the proximal left anterior descending with 50% stenosis in the mid left anterior descending.,5.  severe stenosis at the origin of the large diagonal artery and subtotal stenosis in the mid segment of this diagonal branch.",2
"chief complaint: , this 5-year-old male presents to children's hospital emergency department by the mother with ""have asthma.""  mother states he has been wheezing and coughing.  they saw their primary medical doctor.  he was evaluated at the clinic, given the breathing treatment and discharged home, was not having asthma, prescribed prednisone and an antibiotic.  they told to go to the er if he got worse.  he has had some vomiting and some abdominal pain.  his peak flows on the morning are normal at 150, but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the day.,past medical history:,  asthma with his last admission in 07/2007.  also inclusive of frequent pneumonia by report.,immunizations: , up-to-date.,allergies: , denied.,medications:  ,advair, nasonex, xopenex, zicam, zithromax, prednisone, and albuterol.,past surgical history: , denied.,social history: , lives at home, here in the ed with the mother and there is no smoking in the home.,family history: , no noted exposures.,review of systems:  ,documented on the template.  systems reviewed on the template.,physical examination:,vital signs:  temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5 kg.  oxygen saturation low at 91% on room air.,general:  this is a well-developed male who is cooperative, alert, active with oxygen by facemask.,heent:  head is atraumatic and normocephalic.  pupils are equal, round, and reactive to light.  extraocular motions are intact and conjugate.  clear tms, nose, and oropharynx.,neck:  supple.  full painless nontender range of motion.,chest:  tight wheezing and retractions heard bilaterally.,heart:  regular without rubs or murmurs.,abdomen:  soft, nontender.  no masses.  no hepatosplenomegaly.,genitalia:  male genitalia is present on a visual examination.,skin:  no significant bruising, lesions or rash.,extremities:  moves all extremities without difficulty, nontender.  no deformity.,neurologic:  symmetric face, cooperative, and age appropriate.,medical decision making:,  the differential entertained on this patient includes reactive airways disease, viral syndrome, and foreign body pneumonia.  he is evaluated in the emergency department with continuous high-dose albuterol, decadron by mouth, pulse oximetry, and close observation.  chest x-ray reveals bronchial thickening, otherwise no definite infiltrate.  she is further treated in the emergency department with continued breathing treatments.  at 0048 hours, he has continued tight wheezes with saturations 99%, but ed sats are 92% with coughing spells.  based on the above, the hospitalist was consulted and accepts this patient for admission to the hospital with the working diagnosis of respiratory distress and asthma.",11
"preoperative diagnosis: , right breast mass with atypical proliferative cells on fine-needle aspiration.,postoperative diagnosis:,  benign breast mass.,anesthesia: , general,name of operation:,  excision of right breast mass.,procedure:,  with the patient in the supine position, the right breast was prepped and draped in a sterile fashion.  a curvilinear incision was made directly over the mass in the upper-outer quadrant of the right breast.  dissection was carried out around a firm mass, which was dissected with surrounding margins of breast tissue.  hemostasis was obtained using electrocautery.  frozen section exam showed a fibroadenoma with some proliferative hyperplasia within the fibroadenoma, but appeared benign.  the breast tissues were approximated using 4-0 vicryl.  the skin was closed using 5-0 vicryl running subcuticular stitches.  a sterile bandage was applied.  the patient tolerated the procedure well.,",22
"exam: , ct of the abdomen and pelvis without contrast.,history: , lower abdominal pain.,findings:,  limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  there is a 1.6 cm nodular density at the left posterior sulcus.,noncontrast technique limits evaluation of the solid abdominal organs.  cardiomegaly and atherosclerotic calcifications are seen.,hepatomegaly is observed.  there is calcification within the right lobe of the liver likely related to granulomatous changes.  subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  there is splenomegaly seen.  there are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  the pancreas appears atrophic.  there is a left renal nodule seen, which measures 1.9 cm with a hounsfield unit density of approximately 29, which is indeterminate.,there is mild bilateral perinephric stranding.  there is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  there is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  bilateral ureters appear normal in caliber along their visualized course.  the bladder is partially distended with urine, but otherwise unremarkable.,postsurgical changes of hysterectomy are noted.  there are pelvic phlebolith seen.  there is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,scattered colonic diverticula are observed.  the appendix is within normal limits.  the small bowel is unremarkable.  there is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  the hernia neck measures approximately 2.7 cm.  there is stranding of the fat within the hernia sac.,there are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  degenerative changes of the spine are observed.,impression:,1.  anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  nodule in the left lower lobe, recommend follow up in 3 months.,3.  indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol ct or mri.,4.  hepatomegaly with changes suggestive of cirrhosis.  there is also splenomegaly observed.,5.  low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.",19
"indications for procedure:, this is a 61-year-old, white male with onset of chest pain at 04: 30 this morning, with history of on and off chest discomfort over the past several days. cpk is already over 1000. there is st elevation in leads ii and avf, as well as a q wave. the chest pain is now gone, mild residual shortness of breath, no orthopnea. cardiac monitor shows resolution of st elevation lead iii.,description of procedure:, following sterile prep and drape of the right groin, installation of 1% xylocaine anesthesia, the right common femoral artery was percutaneously entered and 6-french sheath inserted. act approximately 165 seconds on heparin. borderline hypotension 250 ml fluid bolus given and nitroglycerin patch removed. selective left and right coronary injections performed using judkins coronary catheters with a 6-french pigtail catheter used to obtain left ventricular pressures and left ventriculography. left pullback pressure. sheath injection. hemostasis obtained with a 6-french angio-seal device. he tolerated the procedure well and was transported to the cardiac step-down unit in stable condition.,hemodynamic data:, left ventricular end diastolic pressure elevated post a-wave at 25 mm of mercury with no aortic valve systolic gradient on pullback.,angiographic findings:,i. left coronary artery: the left main coronary artery is unremarkable. the left anterior descending has 30 to 40% narrowing with tortuosity in its proximal portion, patent first septal perforator branch. the first diagonal branch is a 2 mm vessel with a 90% ostial stenosis. the second diagonal branch is unremarkable, as are the tiny distal diagonal branches. the intermediate branch is a small, normal vessel. the ostial non-dominant circumflex has some contrast thinning, but no stenosis, normal obtuse marginal branch, and small av sulcus circumflex branch.,ii. right coronary artery: the right coronary artery is a large, dominant vessel which gives off large posterior descending and posterolateral left ventricular branches. there are luminal irregularities, less than 25%, within the proximal to mid vessel. some contrast thinning is present in the distal rca just before the bifurcation into posterior descending and posterolateral branches. a 25%, smooth narrowing at the origin of the posterior descending branch. posterolateral branch is unremarkable and quite large, with secondary and tertiary branches.,iii. left ventriculogram: the left ventricle is normal in size. ejection fraction estimated at 40 to 45%. no mitral regurgitation. severe hypokinesis to akinesis is present in the posterobasal and posteromedial segments with normal anteroapical wall motion.,discussion:, recent inferior myocardial infarction with only minor contrast thinning distal rca remaining on coronary angiography with resolution of chest pain and st segment elevation. left coronary system has one hemodynamically significant stenosis (a 90% ostial stenosis at the first diagonal branch, which is a 2 mm vessel). left ventricular function is reduced with ejection fraction 40 to 45% with inferior wall motion abnormality.,plan:, medical treatment, including plavix and nitrates, in addition to beta blocker, aspirin, and aggressive lipid reduction.",2
"rheumatoid arthritis, (or ra) is a chronic, systemic condition with primary involvement of the joints.  joint inflammation is present due to an abnormal immune response in which the body attacks its own tissue.  specifically, the tissues lining the joint are involved as well as cartilage and muscle and sometimes the eyes and blood vessels.  the cause of rheumatoid arthritis is obscure but it is associated with a family history, genetic and autoimmune problems, people ages 20-60, female gender 3:1 or a native american background.,signs and symptoms:,*  joint pain, swelling, redness, warmth.  commonly involved joints are the small joints of the hands and feet and the ankles, wrists, knees, shoulders and elbows.,*  multiple swollen joints (more than 3) with simultaneous involvement of same joints on opposite side of the body.,*  morning stiffness that lasts longer than 30 minutes.,*  difficulty making a fist; poor grip strength.,*  night pain.,*  feeling ""sick"" - low fever, loss of appetite, tiredness, generalized aching and stiffness, weakness.,*  rheumatoid nodules under the skin, usually along the surface of tendons or over bony prominences.,*  disease may lead to deformed joints, decreased vision, anemia, muscle weakness, peripheral nerve problems, pericarditis, enlarged spleen, increased frequency of infections.,*  blood tests will reveal a positive rheumatoid factor (rf) to be present the majority of the time.,treatment:,*  to diagnose ra, blood studies are done to detect a substance known as rheumatoid factor and x-rays may show typical findings.,*  night splints for involved joints.  avoid putting a pillow under the knees as this will contribute to joint contracture.,*  heat helps relieve the pain; hot water soaks, whirlpool baths, heat lamps, heating pads, etc. applied to affected joints 15-20 minutes 3 times per day is helpful.,*  sleep on a firm mattress and sleep at least 10-12 hours per night.  get rest during the day; take naps.,*  get bed rest during an active flare-up until symptoms subside.,*  avoid humid weather if possible.,*  nsaids (non-steroidal anti-inflammatory drugs).,*  dmards (disease-modifying anti-rheumatic drugs) - gold compounds, d-penicillamine, sulfasalazine, methotrexate, antimalarials.,*  immunosuppressive drugs.,*  acetaminophen (tylenol) for pain relief only when necessary.,*  oral corticosteroids short term; corticosteroid injection into joint can temporarily relieve pain and inflammation.,*  exercise as recommended by your physician.  exercise helps keep the joints limber and increases strength.  swimming and water activities are a good way to workout.  put all your joints through their full ranges of motion every day to prevent contractures. *  physical therapy may be recommended.,*  surgical intervention.,*  lose excess weight as being overweight will only stress the joints further.,*  eat a normal, well-balanced diet.",32
"circumcision - neonatal,procedure:,:  the procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  she is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  the infant was placed on the papoose board.  the external genitalia were prepped with betadine.  a penile block was performed with a 30-gauge needle and 1.5 ml of nesacaine without epinephrine.,next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  the incision was made.  next, all the adhesions of the inner preputial skin were broken down.  the appropriate size bell was obtained and placed over the glans penis.  the gomco clamp was then configured, and the foreskin was pulled through the opening of the gomco.  the bell was then placed and tightened down.  prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  a blade was used to incise circumferentially around the bell.  the bell was removed.  there was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,vaseline gauze was then placed.  the little boy was given back to his mom.,plan:,  they have a new baby checkup in the near future with their primary care physician.  i will see them back on a p.r.n. basis if there are any problems with the circumcision.",36
"preoperative diagnosis:,  left inguinal hernia.,postoperative diagnosis: , left inguinal hernia, direct.,procedure: , left inguinal herniorrhaphy, modified bassini.,description of procedure:  ,the patient was electively taken to the operating room.  in same day surgery, dr. x applied a magnet to the pacemaker defibrillator that the patient has to change it into a fixed mode and to protect the device from the action of the cautery.  informed consent was obtained, and the patient was transferred to the operating room where a time-out process was followed and the patient under general endotracheal anesthesia was prepped and draped in the usual fashion.  local anesthesia was used as a field block and then an incision was made in the left inguinal area and carried down to the external oblique aponeurosis, which was opened.  the cord was isolated and protected.  it was dissected out.  the lipoma of the cord was removed and the sac was high ligated.  the main hernia was a direct hernia due to weakness of the floor.  a bassini repair was performed.  we used a number of interrupted sutures of 2-0 tevdek __________ in the conjoint tendon and the ilioinguinal ligament.,the external oblique muscle was approximated same as the soft tissue with vicryl and then the skin was closed with subcuticular suture of monocryl.  the dressing was applied and the patient tolerated the procedure well, estimated blood loss was minimal, was transferred to recovery room in satisfactory condition.",37
"subjective:,  this is a 12-year-old male who comes in for healthy checkups and sports physical.  no major concerns today.  he is little bit congested at times.  he has been told he is allergic to grasses.  they have done over-the-counter claritin and that seems to help but he is always sniffling mother reports.  he has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,past medical history:,  otherwise, reviewed.  very healthy.,current medications:,  claritin p.r.n.,allergies to medicines:,  none.,family social history:,  everyone else is healthy at home currently.,dietary:,  he is on whole milk and does a variety of foods.  growth chart is reviewed with mother.  voids and stools well.,developmental:,  he is in seventh grade and going out for cross-country and track.  he is supposed to be wearing glasses, is not today.  we did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  his hearing was normal today and no concerns with speech.,physical examination:,general:  a well-developed, well-nourished male in no acute distress.,dermatologic:  without rash or lesion.,heent:  head normocephalic and atraumatic.  eyes:  pupils equal, round and reactive to light.  extraocular movements intact.  red reflexes are present bilaterally.  optic discs are sharp with normal vasculature.  ears:  tympanic membranes are gray, translucent with normal light reflex.  nares are very congested.  turbinates swollen and boggy.,neck:  supple without masses.,chest:  clear to auscultation and percussion, easy respirations.  no accessory muscle use.,cardiovascular:  regular rate and rhythm without murmurs, rubs, heaves or gallops.,back:  symmetric with no scoliosis or kyphosis noted.  normal flexibility.  femoral pulses 2+ and symmetric.,abdomen:  soft, nontender, nondistended without hepatosplenomegaly.,gu exam:  normal tanner iii male.  testes descended bilaterally.  no abnormal rash, discharge, or scars.,extremities:  pink and warm.  moves all extremities well with normal function and strength in the arms and legs.  normal balance, station, and gait.  normal speech.,neurologic:  nonfocal with normal speech, station, gait, and balance.,assessment:,  healthy tanner iii male, developing normally.,plan:,1.  diet, growth, safety, drugs, violence, and social competence all discussed.,2.  immunizations reviewed.,3.  we will place him on clarinex 5 mg once daily, some rhinocort-aq nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.",4
"history: , neurologic consultation was requested to assess and assist with her seizure medication.  the patient is a 3-year 3 months old girl with refractory epilepsy.  she had been previously followed by xyz, but has been under the care of the ucsf epilepsy program and recently by dr. y.  i reviewed her pertinent previous neurology evaluations at chcc and also interviewed mom.,the patient had seizure breakthrough in august 2007, which requires inpatient admission, thanksgiving and then after that time had seizures every other day, up-to-date early december.  she remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with diastat.  she presented to our er today with prolonged convulsive seizure despite receiving 20 mg of diastat at home.  mom documented 103 temperature at home.  in the er, this was 101 to 102 degrees fahrenheit.  i reviewed the er notes.  at 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5.  ucsf fellow was contacted.  she was given additional fosphenytoin and had a total dose of 15 mg/kg administered.  vital weight was 27.  seizures apparently had stopped.  the valproic acid level obtained at 0835 hours was 79.  according to mom, her last dose was at 6 p.m. and she did not receive her morning dose.  other labs slightly showed leukocytosis with white blood cell count 21,000 and normal cmp.,previous workup here showed an eeg on 2005, which showed a left posterior focus.  mri on june 2007 and january 2005 were within normal limits.  mom describes the following seizure types:,1.  eye blinking with unresponsiveness.,2.  staring off to one side.,3.  focal motor activity in one arm and recently generalized tonic seizure.,she also said that she was supposed to see dr. y this friday, but had postponed it to some subsequent time when results of genetic testing would be available.  she was being to physicians' care as dr. z had previously being following her last ucsf.,she had failed most of the first and second line anti-epileptic drugs.  these include keppra, lamictal, trileptal, phenytoin and phenobarbital.  these are elicited to allergies, but she has not had any true allergic reactions to these.  actually, it has resulted in an allergic reaction resulting in rash and hypotension.,she also had been treated with clobazam.  her best control is with her current regimen of valproic acid and tranxene.  other attempts to taper topamax, but this resulted increased seizures.  she also has oligohidrosis during this summertime.,current medications: , include diastat 20 mg; topamax 25 mg b.i.d., which is 3.3 per kilo per day; tranxene 15 mg b.i.d.; depakote 125 mg t.i.d., which is 25 per kilo per day.,physical examination:,vital signs:  weight 15 kg.,general:  the patient was awake, she appeared sedated and postictal.,neck:  supple.,neurological:  she had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,she was able to follow commands such as when i request that she gave mom a kiss.  she acknowledged her doll.  left fundus is sharp.  she resisted the rest of the exam.  there was no obvious lateralized findings.,assessment:,  status epilepticus resolved.  triggered by a febrile illness, possibly viral.  refractory remote symptomatic partial epilepsy.,impression: , i discussed the maximizing depakote to mom and she concurred.  i recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime.  for today, she did give an iv depacon 250 mg and the above dosage can be continued iv until she is taking p.o.  dr. x agreed with the changes and orders were written for this.  she can continue her current doses of topamax and tranxene.  this can be given by ng if needed.  topamax can be potentially increased to 25 mg in the morning and 50 mg at night.  i will be available as needed during the rest of her hospitalization.  mom will call contact dr. y an update him about the recent changes.",4
"admission diagnosis: , right tibial plateau fracture.,discharge diagnoses: , right tibial plateau fracture and also medial meniscus tear on the right side.,procedures performed:,  open reduction and internal fixation (orif) of right schatzker iii tibial plateau fracture with partial medial meniscectomy.,consultations: , to rehab, dr. x and to internal medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,hospital course: , the patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right schatzker iii tibial plateau fracture and partial medial meniscectomy performed without incidence.  the patient seemed to be recovering well.  the patient spent the next several days on the floor, nonweightbearing with cpm machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  the patient was given nebulizer treatment and lasix increased the same to resolve the problem.  the patient was comfortable, stabilized, breathing well.  on day #12, was transferred to abcd.,discharge instructions: , the patient is to be transferred to abcd after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,diet:,  regular.,activity and limitations: , nonweightbearing to the right lower extremity.  the patient is to continue cpm machine while in bed along with antiembolic stockings.  the patient will require nursing, physical therapy, occupational therapy, and social work consults.,discharge medications: , resume home medications, but increase lasix to 80 mg every morning, lovenox 30 mg subcu daily x2 weeks, vicodin 5/500 mg one to two every four to six hours p.r.n. pain, combivent nebulizer every four hours while awake for difficulty breathing, zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,followup: , follow up with dr. y in 7 to 10 days in office.,condition on discharge:,  stable.",9
"preoperative diagnoses,1.  bowel obstruction.,2.  central line fell off.,postoperative diagnoses,1.  bowel obstruction.,2.  central line fell off.,procedure: , insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,procedure detail: , this lady has a bowel obstruction.  she was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  at the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  xylocaine 1% was infiltrated and with the patient in trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  a seldinger technique was used and a triple-lumen catheter was inserted.  there was a good flow through all three ports, which were irrigated with saline prior to connection to the iv solutions.,the catheter was affixed to the skin with sutures and then a dressing was applied.,the postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.",36
"preoperative diagnosis: , nausea and vomiting and upper abdominal pain.,post procedure diagnosis:  ,normal upper endoscopy.,operation: , esophagogastroduodenoscopy with antral biopsies for h. pylori x2 with biopsy forceps.,anesthesia:,  iv sedation 50 mg demerol, 8 mg of versed.,procedure: , the patient was taken to the endoscopy suite.  after adequate iv sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  a bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  the first, second, and third portions of the duodenum were normal.  the scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for h. pylori.  the scope was retroflexed which showed a normal ge junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  the scope was withdrawn at the ge junction which was in a normal position with a normal transition zone.  the scope was then removed throughout the esophagus which was normal.  the patient tolerated the procedure well.,the plan is to obtain a hida scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.",36
"preoperative diagnoses: , c5-c6 disc herniation with right arm radiculopathy.,postoperative diagnoses: , c5-c6 disc herniation with right arm radiculopathy.,procedure:,1.  c5-c6 arthrodesis, anterior interbody technique.,2.  c5-c6 anterior cervical discectomy.,3.  c5-c6 anterior instrumentation with a 23-mm mystique plate and the 13-mm screws.,4.  implantation of machine bone implant.,5.  microsurgical technique.,anesthesia:  ,general endotracheal.,estimated blood loss: , less than 100 ml.,background information and surgical indications:  ,the patient is a 45-year-old right-handed gentleman who presented with neck and right arm radicular pain.  the pain has become more and more severe.  it runs to the thumb and index finger of the right hand and it is accompanied by numbness.  if he tilts his neck backwards, the pain shoots down the arm.  if he is working with the computer, it is very difficult to use his mouse.  he tried conservative measures and failed to respond, so he sought out surgery.  surgery was discussed with him in detail.  a c5-c6 anterior cervical discectomy and fusion was recommended.  he understood and wished to proceed with surgery.  thus, he was brought in same day for surgery on 07/03/2007.,description of procedure: , he was given ancef 1 g intravenously for infection prophylaxis and then transported to the or.  there general endotracheal anesthesia was induced.  he was positioned on the or table with an iv bag between the scapulae.  the neck was slightly extended and taped into position.  a metal arch was placed across the neck and intraoperative x-ray was obtain to verify a good position for skin incision and the neck was prepped with betadine and draped in the usual sterile fashion.,a linear incision was created in the neck beginning just to the right of the midline extending out across the anterior border of the sternocleidomastoid muscle.  the incision was extended through skin, subcutaneous fat, and platysma.  hemostasis was assured with bovie cautery.  the anterior aspect of the sternocleidomastoid muscle was identified and dissection was carried medial to this down to the carotid sheath.  the trachea and the esophagus were swept out of the way and dissection proceeded medial to the carotid sheath down between the two bellies of the longus colli muscle on to the anterior aspect of the spine.  a bovie cautery was used to mobilize the longus colli muscle around initially what turned out to be c6-c7 disk based on x-rays and then around the c5-c6 disk space.  an intraoperative x-ray confirmed c5-c6 disk space had been localized and then the self-retained distraction system was inserted to maintain exposure.  a 15-blade knife was used to incise the c5-c6 disk and remove disk material. and distraction pins were inserted into c5-c6 and distraction placed across the disk space.  the operating microscope was then brought into the field and used throughout the case except for the closure.  various pituitaries, #15 blade knife, and curette were used to evacuate the disk as best as possible.  then, the midas rex drill was taken under the microscope and used to drill where the cartilaginous endplate driven back all the way into the posterior aspect of the vertebral body.  a nerve hook was swept underneath the posterior longitudinal ligament and a fragment of disk was produced and was pulled up through the ligament.  a kerrison rongeur was used to open up the ligament in this opening and then to march out in the both neural foramina.  a small amount of disk material was found at the right neural foramen.  after a good decompression of both neural foramina was obtained and the thecal sac was exposed throughout the width of the exposure, the wound was thoroughly irrigated.  a spacing mechanism was intact into the disk space and it was determined that a #7 spacer was appropriate.  so, a #7 machine bone implant was taken and tapped into disk space and slightly counter sunk.  the wound was thoroughly irrigated and inspected for hemostasis.  a mystique plate 23 mm in length was then inserted and anchored to the anterior aspect of c5-c6 to hold the bone into position and the wound was once again irrigated.  the patient was valsalved.  there was no further bleeding seen and intraoperative x-ray confirmed a good position near the bone, plate, and screws and the wound was enclosed in layers.  the 3-0 vicryl was used to approximate platysma and 3-0 vicryl was used in inverted interrupted fashion to perform a subcuticular closure of the skin.  the wound was cleaned.,mastisol was placed on the skin, and steri-strips were used to approximate skin margins.  sterile dressing was placed on the patient's neck.  he was extubated in the or and transported to the recovery room in stable condition.  there were no complications.",21
"duplex ultrasound of legs,right leg:,  duplex imaging was carried out according to normal protocol with a 7.5 mhz imaging probe using b-mode ultrasound.  deep veins were imaged at the level of the common femoral and popliteal veins.  all deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,the long saphenous system displayed compressibility without evidence of thrombosis.  the long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  the small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,left leg:,  duplex imaging was carried out according to normal protocol with a 7.5 mhz imaging probe using b-mode ultrasound.  deep veins were imaged at the level of the common femoral and popliteal veins.  all deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,the long saphenous system displayed compressibility without evidence of thrombosis.  the long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  the small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.",2
"preoperative diagnosis:  ,bilateral carpal tunnel syndrome.,postoperative diagnosis: , bilateral carpal tunnel syndrome.,procedures:,1.  right open carpal tunnel release.,2.  cortisone injection, left carpal tunnel.,anesthesia: , general lma.,estimated blood loss: , minimal.,complications:,  none.,indications:,  this patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  he is scheduled for the above-mentioned procedures.  the planned procedures were discussed with the patient including the associated risks.  the risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  he voiced understanding and agreed to proceed as planned.,description of procedure: , the patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  informed consent was obtained.  the patient was then brought to the operating room and transferred to the operating table in supine position.  time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,after adequate general lma anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  the right upper extremity was then prepped and draped in the usual sterile fashion.  planned skin incision was marked along the base of the patient's right palm.  right upper extremity was then exsanguinated using esmarch.  the tourniquet was then inflated to 250 mmhg.  skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  bleeding points were identified with electrocautery using bipolar electrocautery.  retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  baby metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  this was confirmed by visually and palpably.  next, baby metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  carpal canal was then inspected.  the median nerve was flattened and injected.  no other abnormalities were noted.  wounds were then irrigated with normal saline and antibiotic additive.  decadron 4 mg was then placed adjacent to the median nerve.  skin incision was then closed with interrupted 5-0 nylon suture.  the wound was then dressed with adaptic, 4 x 4s, kling, and coban.  the tourniquet was then deflated.  attention was then directed to the left side.  using sterile technique, the left carpal canal was injected with a mixture of 40 mg of depo-medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% marcaine.  band-aid was then placed over the injection site.  the patient was then awakened, extubated, and transferred over to his hospital bed.  he was transported to recovery room in stable condition.  there were no intraoperative or immediate postoperative complications.  all counts were reported as correct.",36
"preoperative diagnoses:,1.  request for cosmetic surgery.,2.  facial asymmetry following motor vehicle accident.,postoperative diagnoses:,1.  request for cosmetic surgery.,2.  facial asymmetry following motor vehicle accident.,procedures:,1.  endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,anesthesia: , general via endotracheal tube.,indications for operation: , the patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  she had requested a procedure to bring about further facial asymmetry.  she was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  she did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  preoperative workup including ct scan failed to show any skeletal trauma.  the patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,procedure:,  the patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  general endotracheal anesthesia was induced with a #6 endotracheal tube.  all appropriate measures were taken to preserve the vocal cords in a professional singer.  local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  the upper eyelids were injected with 1 cc of 1% xylocaine with 1:100,000 units of epinephrine.  adequate time for vasoconstriction and anesthesia was allowed to be obtained.  the patient was prepped and draped in the usual sterile fashion.  a 4-0 silk suture was placed in the right lower lid.  for traction, it was brought anteriorly.  the conjunctiva was incised with the needle tip bovie with jaeger lid plate protecting the cornea and globe.  a q-tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  the middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  the inferior oblique muscle was identified, preserved, and protected throughout the procedure.  the transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  contralateral side was treated in similar fashion with like results and throughout the procedure.  lacri-lube was in the eyes in order to maintain hydration.  attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  a 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  subperiosteal dissection was carried out over the zygomatic arch and whitnall's tubercle and the temporal dissection was completed.,next, bilateral gingivobuccal sulcus incisions were made and a joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to whitnall's tubercle.  the two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  it was bipolar electrocauteried and the tunnel was further dissected free and opened.  the endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  the guard was removed and the suspension spikes were engaged into the soft tissues.  the spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  the endotine device was then secured to the true temporal fascia with three sutures of 3-0 pds suture.  contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  the gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  the sterile dressing was applied.  the patient was awakened in the operating room and taken to the recovery room in good condition.",5
"preoperative diagnosis: , cataract, right eye.,postoperative diagnosis:,  cataract, right eye.,procedure:,  phacoemulsification with intraocular lens placement, right eye.,anesthesia: , monitored anesthesia care,estimated blood loss: , none,complications:,  none,specimens:,  none,procedure in detail: , the patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  the patient had the risks and benefits of surgery discussed.  after discussion, the patient decided to proceed and the consent was signed.,on the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  following this, the patient was sterilely prepped and draped in the usual fashion.  after this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the supersharp blade was used to make an anterior chamber paracentesis.  preservative-free lidocaine was instilled into the anterior chamber, and then viscoat was instilled into the eye.,the 3.0 diamond keratome was then used to make a clear corneal temporal incision.  following this, the cystotome was used to make a continuous tear-type capsulotomy.  after this, bss was used to hydrodissect and hydrodelineate the lens.  the phacoemulsification unit was used to remove the cataract.  the i&a unit was used to remove the residual cortical material.  following this, provisc was used to inflate the bag.  the lens, a model sa60at of abcd diopters, serial #1234, was inserted into the bag and rotated into position using the lester pusher.,after this, the residual provisc was removed.  michol was instilled and then the corneal wound was hydrated with bss, and the wound was found to be watertight.  the lid speculum was removed.  acular and vigamox drops were placed.  the patient tolerated the procedure well without complications and will be followed up in the office tomorrow.",36
"ears, nose, mouth and throat,ears/nose: , the auricles are normal to palpation and inspection without any surrounding lymphadenitis.  there are no signs of acute trauma.  the nose is normal to palpation and inspection externally without evidence of acute trauma.  otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  the tympanic membranes are without disruption or infection.  hearing intact bilaterally to normal level speech.  nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  the septum is without acute traumatic lesions or disruption.  the turbinates are without abnormal swelling.  there is no unusual rhinorrhea or bleeding.  ,lips/teeth/gums:  ,the lips are without infection, mass lesion or traumatic lesions.  the teeth are intact without obvious signs of infection.  the gingivae are normal to palpation and inspection.  ,oropharynx:  ,the oral mucosa is normal.  the salivary glands are without swelling.  the hard and soft palates are intact.  the tongue is without masses or swelling with normal movement.  the tonsils are without inflammation.  the posterior pharynx is without mass lesion with good patent oropharyngeal airway.",14
"preoperative diagnosis: , lumbar stenosis.,postoperative diagnoses:,  lumbar stenosis and cerebrospinal fluid fistula.,title of the operation,1.  lumbar laminectomy for decompression with foraminotomies l3-l4, l4-l5, l5-s1 microtechniques.,2.  repair of csf fistula, microtechniques l5-s1, application of duraseal.,indications:,  the patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  she was evaluated with an mri scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at c4-c5, c5-c6, and c6-c7 as well as a complete block of the contrast at l4-l5 and no contrast at l5-s1 either and stenosis at l3-l4 and all the way up, but worse at l3-l4, l4-l5, and l5-s1.  yesterday, she underwent an anterior cervical discectomy and fusions c4-c5, c5-c6, c6-c7 and had some improvement of her symptoms and increased strength, even in the recovery room.  she was kept in the icu because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  the rationale for putting the surgery is close together that she is normally on coumadin for atrial fibrillation, though she has been cardioverted.  she and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,procedure: , the patient was brought from the neuro icu to the operating room, where general endotracheal anesthesia was obtained.  she was rolled in a prone position on the wilson frame.  the back was prepared in the usual manner with betadine soak, followed by betadine paint.  markings were applied.  sterile drapes were applied.  using the usual anatomical landmarks, linear midline incision was made presumed over l4-l5 and l5-s1.  sharp dissection was carried down into subcutaneous tissue, then bovie electrocautery was used to isolate the spinous processes.  a kocher clamp was placed in the anterior spinous ligament and this turned out to be l5-s1.  the incision was extended rostrally and deep gelpi's were inserted to expose the spinous processes and lamina of l3, l4, l5, and s1.  using the leksell rongeur, the spinous processes of l4 and l5 were removed completely, and the caudal part of l3.  a high-speed drill was then used to thin the caudal lamina of l3, all of the lamina of l4 and of l5.  then using various kerrison punches, i proceeded to perform a laminectomy.  removing the l5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  there was csf leak.  the lamina removal was continued, ligamentum flavum was removed to expose all the dura.  then using 4-0 nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  there was no csf leak with valsalva.,i then continued the laminectomy removing all of the lamina of l5 and of l4, removing the ligamentum flavum between l3-l4, l4-l5 and l5-s1.  foraminotomies were accomplished bilaterally.  the caudal aspect of the lamina of l3 also was removed.  the dura came up quite nicely.  i explored out along the l4, l5, and s1 nerve roots after completing the foraminotomies, the roots were quite free.  further more, the thecal sac came up quite nicely.  in order to ensure no csf leak, we would follow the patient out of the operating room.  the dural closure was covered with a small piece of fat.  this was all then covered with duraseal glue.  gelfoam was placed on top of this, then the muscle was closed with interrupted 0 ethibond.  the lumbodorsal fascia was closed with multiple sutures of interrupted 0 ethibond in a watertight fashion.  scarpa's fascia was closed with a running 0 vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  the wound was blocked with 0.5% plain marcaine.,estimated blood loss:  estimated blood loss for the case was about 100 ml.,sponge and needle counts:  correct.,findings:  a very tight high-grade stenosis at l3-l4, l4-l5, and l5-s1.  there were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,the patient tolerated the procedure well with stable vitals throughout.",25
"procedures performed:,1. left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. left ventricular angiography was not performed.,3. right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. right femoral artery angiography.,5. perclose to seal the right femoral arteriotomy.,indications for procedure:, patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. the patient presented with what appeared to be a copd exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-st elevation myocardial infarction. he was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,description of procedure:, after informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. the patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. then, a 6-french sheath was inserted into the right femoral artery. over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-french jl4 diagnostic catheter to image the left coronary artery, a 6-french jr4 diagnostic catheter to image the right coronary artery, a 6-french angled pigtail catheter to measure left ventricular pressure. at the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. then, a perclose was used to seal the right femoral arteriotomy.,hemodynamic data:, the opening aortic pressure was 91/63. the left ventricular pressure was 94/13 with an end-diastolic pressure of 24. left ventricular ejection fraction was not assessed, as ventriculogram was not performed. the patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,coronary angiogram:, the left main coronary artery was angiographically okay. the lad had mild diffuse disease. there appeared to be distal tapering of the lad. the left circumflex had mild diffuse disease. in the very distal aspect of the circumflex after om-3 and om-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. the runoff from this area appeared to be a very small plom type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. the right coronary artery had mild diffuse disease. the plv branch was 100% occluded at its ostium at the crux. the pda at the ostium had an 80% stenosis. the pda was a fairly sizeable vessel with a long course. the right coronary is dominant.,conclusion:, mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. this circumflex appears to be chronically diseased and has areas that appear to be subtotal. there is a 100% plv branch which is also chronic and reported in his angiogram in the 1990s. there is an ostial 80% right pda lesion. the plan is to proceed with percutaneous intervention to the right pda.,the case was then progressed to percutaneous intervention of the right pda. a 6-french jr4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. the lesion was crossed with a long bmw 0.014 guidewire. then, we ballooned the lesion with a 2.5 x 9 mm maverick balloon. subsequently, we stented the lesion with a 2.5 x 16 mm taxus drug-eluting stent with a nice angiographic result. the patient tolerated the procedure very well, without complications.,angioplasty conclusion:, successful percutaneous intervention with drug-eluting stent placement to the ostium of the pda.,recommendations:, aspirin indefinitely, and plavix 75 mg p.o. daily for no less than six months. the patient will be dispositioned back to telemetry for further monitoring.,total medications during procedure:, versed 1 mg and fentanyl 25 mcg for conscious sedation. heparin 8400 units iv was given for anticoagulation. ancef 1 g iv was given for closure device prophylaxis.,contrast administered:, 200 ml.,fluoroscopy time:, 12.4 minutes.",36
"post procedure instructions:, the patient has been asked to report to us any redness, swelling, inflammation, or fevers.  the patient has been asked to restrict the use of the * extremity for the next 24 hours.",26
"1.  pelvic tumor.,2.  cystocele.,3.  rectocele.,postoperative diagnoses:,1.  degenerated joint.,2.  uterine fibroid.,3.  cystocele.,4.  rectocele.,procedure performed:  ,1.  total abdominal hysterectomy.,2.  bilateral salpingooophorectomy.,3.  repair of bladder laceration.,4.  appendectomy.,5.  marshall-marchetti-krantz cystourethropexy.,6.  posterior colpoperineoplasty.,gross findings:  the patient had a history of a rapidly growing mass on the abdomen, extending from the pelvis over the past two to three months.  she had a recent d&c and laparoscopy, and enlarged mass was noted and could not be determined if it was from the ovary or the uterus.  curettings were negative for malignancy.  the patient did have a large cystocele and rectocele, and a collapsed anterior and posterior vaginal wall.,upon laparotomy, there was a giant uterine tumor extending from the pelvis up to the above the umbilicus compatible with approximately four to five-month pregnancy.  the ovaries appeared to be within normal limits.  there was marked adherence between the bladder and the giant uterus and mass with edema and inflammation, and during dissection, a laceration inadvertently occurred and it was immediately recognized.  no other pathology noted from the abdominal cavity or adhesions.  the upper right quadrant of the abdomen compatible with a previous gallbladder surgery.  the appendix is in its normal anatomic position.  the ileum was within normal limits with no meckel's diverticulum seen and no other gross pathology evident.  there was no evidence of metastasis or tumors in the left lobe of the liver.,upon frozen section, diagnosis of initial and partial is that of a degenerating uterine fibroid rather than a malignancy.,operative procedure:  the patient was taken to the operating room, prepped and draped in the low lithotomy position under general anesthesia.  a midline incision was made around the umbilicus down to the lower abdomen.  with a #10 bard parker blade knife, the incision was carried down through the fascia.  the fascia was incised in the midline, muscle fibers were splint in the midline, the peritoneum was grasped with hemostats and with a #10 bard parker blade after incision was made with mayo scissors.  a balfour retractor was placed into the wound.  this giant uterus was soft and compatible with a possible leiomyosarcoma or degenerating fibroid was handled with care.  the infundibular ligament on the right side was isolated and ligated with #0 vicryl suture brought to an avascular area, doubly clamped and divided from the ovary and the ligament again re-ligated with #0 vicryl suture.  the right round ligament was ligated with #0 vicryl suture, brought to an avascular space within the broad ligament and divided from the uterus.  the infundibulopelvic ligament on the left side was treated in a similar fashion as well as the round ligament.  an attempt was made to dissect the bladder flap from the anterior surface of the uterus and this was remarkably edematous and difficult to do, and during dissection the bladder was inadvertently entered.  after this was immediately recognized, the bladder flap was wiped away from the anterior surface of the uterus.  the bladder was then repaired with a running locking stitch #0 vicryl suture incorporating serosal muscularis mucosa and then the second layer of overlapping seromuscular sutures were used to make a two-layer closure of #0 vicryl suture.  after removing the uterus, the bladder was tested with approximately 400 cc of sterile water and there appeared to be no leak.  progressing and removing of the uterus was then carried out and the broad ligament was clamped bilaterally with a straight ochsner forceps and divided from the uterus with mayo scissors, and the straight ochsner was placed by #0 vicryl suture thus controlling the uterine blood supply.  the cardinal ligaments containing the cervical blood supply was serially clamped bilaterally with a curved ochsner forceps, divided from the uterus with #10 bard parker blade knife and a curved ochsner was placed by #0 vicryl suture.  the cervix was again grasped with a lahey tenaculum and pubovesicocervical ligament was entered and was divided using #10 bard parker blade knife and then the vaginal vault and with a double pointed sharp scissors.  a single-toothed tenaculum was placed on the cervix and then the uterus was removed from the vagina using hysterectomy scissors.  the vaginal cuff was then closed using a running #0 vicryl suture in locking stitch incorporating all layers of the vagina, the cardinal ligaments of the lateral aspect and uterosacral ligaments on the posterior aspect.  the round ligaments were approximated to the vaginal cuff with #0 vicryl suture and the bladder flap approximated to the round ligaments with #000 vicryl suture.  the ______ was re-peritonealized with #000 vicryl suture and then the cecum brought into the incision.  the pelvis was irrigated with approximately 500 cc of water.  the appendix was grasped with babcock forceps.  the mesoappendix was doubly clamped with curved hemostats and divided with metzenbaum scissors.  the curved hemostats were placed with #00 vicryl suture.  the base of the appendix was ligated with #0 plain gut suture, doubly clamped and divided from the distal appendix with #10 bard parker blade knife, and the base inverted with a pursestring suture with #00 vicryl.  no bleeding was noted.  sponge, instrument, and needle counts were found to be correct.  all packs and retractors were removed.  the peritoneum muscle fascia was closed in single-layer closure using running looped #1 pds, but prior to closure, a marshall-marchetti-krantz cystourethropexy was carried out by dissecting the space of retzius identifying the urethra in the vesical junction approximating the periurethral connective tissue to the symphysis pubis with interrupted #0 vicryl suture.  following this, the abdominal wall was closed as previously described and the skin was closed using skin staples.  attention was then turned to the vagina, where the introitus of the vagina was grasped with an allis forceps at the level of the bartholin glands.  an incision was made between the mucous and the cutaneous junction and then a midline incision was made at the posterior vaginal mucosa in a tunneling fashion with metzenbaum scissors.  the flaps were created bilaterally by making an incision in the posterior connective tissue of the vagina and wiping the rectum away from the posterior vaginal mucosa, and flaps were created bilaterally.  in this fashion, the rectocele was reduced and the levator ani muscles were approximated in the midline with interrupted #0 vicryl suture.  excess vaginal mucosa was excised and the vaginal mucosa closed with running #00 vicryl suture.  the bulbocavernosus and transverse perinei muscles were approximated in the midline with interrupted #00 vicryl suture.  the skin was closed with a running #000 plain gut subcuticular stitch.  the vaginal vault was packed with a betadine-soaked kling gauze sponge.  sterile dressing was applied.  the patient was sent to recovery room in stable condition.",36
"preoperative diagnosis:, hawkins iv talus fracture.,postoperative diagnosis: , hawkins iv talus fracture.,procedure performed:,1.  open reduction internal fixation of the talus.,2.  medial malleolus osteotomy.,3.  repair of deltoid ligament.,anesthesia: , spinal.,tourniquet time: , 90 min.,blood loss:,  50 cc.,the patient is in the semilateral position on the beanbag.,intraoperative findings:,  a comminuted hawkins iv talus fracture with an incomplete rupture of the deltoid ligament.  there was no evidence of osteochondral defects of the talar dome.,history:  ,this is a 50-year-old male who presented to abcd general hospital emergency department with complaints of left ankle pain and disfigurement.  there was no open injury.  the patient fell approximately 10 feet off his liner, landing on his left foot.  there was evidence of gross deformity of the ankle.  an x-ray was performed in the emergency room, which revealed a grade iv hawkins classification talus fracture.  he was distal neurovascularly intact.  the patient denied any other complaints besides pain in the ankle.,it was for this reason, we elected to undergo the above-named procedure in order to reduce and restore the blood supply to the talus body.  because of its tenuous blood supply, the patient is at risk for avascular necrosis.  the patient has agreed to undergo the above-named procedure and consent was obtained.  all risks as well as complications were discussed.,procedure: , the patient was brought back to operative room #4 of abcd general hospital on 08/20/03.  a spinal anesthetic was administered.  a nonsterile tourniquet was placed on the left upper thigh, but not inflated.  he was then positioned on the beanbag.  the extremity was then prepped and draped in the usual sterile fashion for this procedure.  an esmarch was then used to exsanguinate the extremity and the tourniquet was then inflated to 325 mmhg.  at this time, an anteromedial incision was made in order to perform a medial malleolus osteotomy to best localize the fracture region in order to be able to bone graft the comminuted fracture site.  at this time, a #15 blade was used to make approximately 10 cm incision over the medial malleolus.  this was curved anteromedial along the root of the saphenous vein.  the saphenous vein was located.  its tributaries going plantar were cauterized and the vein was retracted anterolaterally.  at this time, we identified the medial malleolus.  there was evidence of approximately 80% avulsion, rupture of the deltoid ligament off of the medial malleolus.  this was a major blood feeder to the medial malleolus and we were concerned, once we were going to do the osteotomy, that this would later create healing problem.  it is for this reason that the pedicle, which was attached to the medial malleolus, was left intact.  this pedicle was the anterior portion of the deltoid ligament.  at this time, a microchoice saw was then used to make a box osteotomy of the medial malleolus.  once this was performed, the medial malleolus was retracted anterolaterally with its remaining pedicle intact for later blood supply.  this provided us with excellent exposure to the fracture site of the medial side.  at this time, any loose comminuted pieces were removed.  the dome of the talus was also checked and did not reveal any osteochondral defects.  there was some comminution on the dorsal aspect of the complete talus fracture and we were concerned that once we place the screw, this would tend to extend the fracture site.  it is for this reason, we did the medial malleolar osteotomy to prevent this from happening in order to best expose the fracture site.  at this time, a reduction was performed.  the #7-0 partially threaded cannulated screws were used in order to fix the fracture.  at this time, a 3.2 mm guidewire was placed going from posterolateral to anteromedial.,this was placed slightly lateral to the achilles tendon, percutaneously inserted, and then drilled in the according fashion across the fracture site.  once this was performed, a skin knife was then used to incise over the percutaneous insertion in order to accommodate the screw going in.  a depth gauze was then used to measure screw length.  a cannulated drill was then used to drill across the fracture site to allow the entrance of the screw.  a 55 mm partially threaded #7-0 cannulated screw was then placed with excellent compression at the fracture site.  once this was obtained, we checked the reduction again using intraoperative xi-scan in the ap and lateral direction.  this projection gave us excellent view of our screw placement and excellent compression across the fracture site.  at this time, we bone grafted the area of comminution using 1 cc of dynagraft with crushed cancellous allograft.  this was placed using a freer elevator into the fracture site where the comminution was.  at this time, we copiously irrigated the wound.  the osteotomy site was then repaired, first clamped using two large tenaculum reduction clamps.  two partially threaded #4-0 cannulated screws were then used to fix the osteotomy site and anatomical reduction was performed with excellent compression across the osteotomy site with the two screws.  next, a #1-0 vicryl was then used to repair the deltoid ligament, which was ruptured via the injury.  a tight repair was performed of the deltoid ligament.  at this time, again copious irrigation was used to irrigate the wound.  a #2-0 vicryl was then used to approximate the subcutaneous skin and staples for the skin incision.  at this time, the leg was cleansed, adaptic, 4 x 4, and kerlix roll were then applied.  the patient was then placed in a plaster splint for mobilization.  the tourniquet was then released.  the patient was then transferred off the operating table to recovery in stable condition.  the prognosis for this fracture is guarded.  there is a high rate of avascular necrosis of the talar body, approximately anywhere from 40-60% risk.  the patient is aware of this and he will be followed as an outpatient for this problem.",25
"exam: , modified barium swallow.,symptom:,  dysphagia with possible aspiration.,findings:,  a cookie deglutition study was performed.  the patient was examined in the direct lateral position.,patient was challenged with thin liquids, thick liquid, semisolids and solids.,persistently demonstrable is the presence of penetration with thin liquids.  this is not evident with thick liquids, semisolids or solids.,there is weakness in the oral phase of deglutition.  subglottic region appears normal.  there is no evidence of aspiration demonstrated.,impression: , penetration demonstrated with thin liquids with weakness of the oral phase of deglutition.",31
"primary diagnosis:,  esophageal foreign body, no associated comorbidities are noted.,procedure:,  esophagoscopy with removal of foreign body.,cpt code: , 43215.,principal diagnosis:,  esophageal foreign body, icd-9 code 935.1.,description of procedure: , under general anesthesia, flexible egd was performed.  esophagus was visualized.  the quarter was visualized at the aortic knob, was removed with grasper.  estimated blood loss 0.  intravenous fluids during time of procedure 100 ml.  no tissues.  no complications.  the patient tolerated the procedure well.  dr. x pipkin attending pediatric surgeon was present throughout the entire procedure.  the patient was transferred from or to pacu in stable condition.",36
"preoperative diagnosis: , right profound mixed sensorineural conductive hearing loss.,postoperative diagnosis:,  right profound mixed sensorineural conductive hearing loss.,procedure performed:,  right middle ear exploration with a goldenberg torp reconstruction.,anesthesia:,  general ,estimated blood loss:,  less than 5 cc.,complications:,  none.,description of findings:,  the patient consented to revision surgery because of the profound hearing loss in her right ear.  it was unclear from her previous operative records and ct scan as to whether or not she was a reconstruction candidate.  she had reports of stapes fixation as well as otosclerosis on her ct scan.,at surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis.  there was no incus.  there was no specific round window niche.  there was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane.  the patient had a type of torp prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,description of the procedure:,  the patient was brought to the operative room and placed in supine position.  the right face, ear, and neck prepped with ***** alcohol solution.  the right ear was draped in the sterile field.  external auditory canal was injected with 1% xylocaine with 1:50,000 epinephrine.  a fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position.  meatal skin was elevated, middle ear was entered.  this exposure included the oval window, round window areas.  there was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum.  the previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate.  the prosthesis was removed without difficulty.  the patient's stapes had an arch, but the ***** was atrophied.  malleus handle was mobile.  the footplate was fixed.  consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane.  the patient was felt to have obliterated otosclerosis of this area along with the stapes fixation.  she is not considered to be a reconstruction candidate under the current circumstances.  no attempt was made to remove bone from the round window area.  a different style of goldenberg torp was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate.  the fit was secure and supported with gelfoam in the middle ear.  the tympanomeatal flap was returned to anatomic position supported with gelfoam saturated ciprodex.  the incision was closed with #4-0 vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.",10
"history of present illness:,  the patient is a 69-year-old single caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, gerd, and dyslipidemia who presents to the emergency room with the complaint of ""manic"" symptoms due to recent medication adjustments.  the patient had been admitted to st. luke's hospital on month dd, yyyy for altered mental status and at that time, the medical team discontinued zyprexa and lithium.  in the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity.  she also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes.  she was admitted voluntarily to the inpatient unit and medications were not restarted for her.  on the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner.  she reports that she would like to speak with dr. a, the neurologist who saw her at st. luke's, because she ""trust him.""  the patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative.  the patient reports that she is originally from brooklyn, new york, and she moved down to houston about a year ago to be with her daughter.  she also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself.  the patient also complains that her daughter is ""trying to tell me what medications to take.""  the patient sees dr. b in the woodlands for outpatient care.,past psychiatric history:,  per chart.  the patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.  she has been stable on lithium and zyprexa according to her daughter and was recently taken off those medications, changed to seroquel, and the daughter reports that she has decompensated since then.  it is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,medications: ,1.  seroquel 100 mg, 1 p.o. b.i.d.,2.  risperdal 1 mg tab, 1 p.o. t.i.d.,3.  actos 30 mg, 1 p.o. daily.,4.  lipitor 10 mg, 1 p.o. at bedtime.,5.  gabapentin 100 mg, 1 p.o. b.i.d.,6.  glimepiride 2 mg, 1 p.o. b.i.d.,7.  levothyroxine 25 mcg, 1 p.o. q.a.m.,8.  protonix 40 mg, 1 p.o. daily.,allergies: , no known drug allergies.,family history:,  per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,social history:,  the patient is from brooklyn, new york and moved to houston approximately one year ago.  she lived independently in an apartment until about one month ago when her daughter moved her into a nursing home.  she has been married once, but her spouse left her when her three children were young.  her children are ages 47, 49, and 51.  she had one year of college, and she currently is retired after working in new york public schools for 20 or more years.  she reports that her spouse was physically abusive to her.  she reports occasional alcohol use and quit smoking 11 years ago.,mental status exam:  ,general:  the patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,behavior:  the patient is singing loudly and joking with interviewers.  she is pleasant, but non-cooperative with interview.,speech:  increased volume, rate, and tone.  normal in flexion and articulation.  motor:  agitated.,mood:  okay.,affect:  elevated and congruent.,thought processes:  tangential and logical at times.,thought contents:  denies suicidal or homicidal ideation.  denies auditory or visual hallucination.  positive grandiose delusions and positive paranoid delusions.,insight:  poor to fair.,judgment:  impaired.  the patient is alert and oriented to person, place, date, year, but not day of the week.,laboratory data:,  sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, bun 23, creatinine 1.1, and calcium 10.6.  acetaminophen level 3.3 and salicylate level less than 0.14.  wbc 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000.  urinalysis within normal limits.,physical examination:,general:  alert and oriented, in no acute distress.,vital signs:  blood pressure 152/92, heart rate 81, and temperature 97.2.,heent:  normocephalic and atraumatic.  perrla.  eomi.  mmm.  op clear.,neck:  supple.  no lad, no jvd, and no bruits.,chest:  clear to auscultation bilaterally.,cardiovascular:  regular rate and rhythm.  s1 and s2 heard.  no murmurs, rubs, or gallops.,abdomen:  obese, soft, nontender, and nondistended.  positive bowel sounds x4.,extremities:  no cyanosis, clubbing, or edema.,assessment:,  this is a 69-year-old caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and gerd who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to st. luke's hospital during which time the patient was taken off her usual medications of lithium and zyprexa.  the patient is manic and disinhibited and is unable to give a sufficient interview at this time.,axis i:  schizoaffective disorder.,axis ii:  deferred.,axis iii:  diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,axis iv:  family strife and recent relocation.,axis v:  gaf equals 25.,plan:  ",30
"description of record:  ,this tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the international 10-20 system.  electrode impedances were measured and reported at less than 5 kilo-ohms each.,findings: , in general, the background rhythms are bilaterally symmetrical.  during the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 hz alpha activity best seen posteriorly.  the alpha activity attenuates with eye opening.,during some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,there is no evidence of focal slowing or paroxysmal activity.,impression: , normal awake and drowsy (stage i sleep) eeg for patient's age.",34
"history of present illness: , the patient is a 68-year-old woman whom i have been following, who has had angina.  in any case today, she called me because she had a recurrent left arm pain after her stent, three days ago, and this persisted after two sublingual nitroglycerin when i spoke to her.  i advised her to call 911, which she did.  while waiting for 911, she was attended to by a physician who is her neighbor and he advised her to take the third nitroglycerin and that apparently relieved her pain.  by the time she presented here, she is currently pain-free and is feeling well.,past cardiac history: , the patient has been having arm pain for several months.  she underwent an exercise stress echocardiogram within the last several months with me, which was equivocal, but then she had a nuclear stress test which showed inferobasilar ischemia.  i had originally advised her for a heart catheterization but she wanted medical therapy, so we put her on a beta-blocker.  however, her arm pain symptoms accelerated and she had some jaw pain, so she presented to the emergency room.  on 08/16/08, she ended up having a cardiac catheterization and that showed normal left main 80%  mid lad lesion, circumflex normal, and rca totally occluded in the mid portion and there were collaterals from the left to the right, as well as right to right to that area.  the decision was made to transfer  her as she may be having collateral insufficiency from the lad stenosis to the rca vessel.  she underwent that with drug-eluting stents on 08/16/08, with i believe three or four total placed, and was discharged on 08/17/08.  she had some left arm discomfort on 08/18/08, but this was mild.  yesterday, she felt very fatigued, but no arm pain, and today, she had arm pain after walking and again it resolved now completely after three sublingual nitroglycerin.  this is her usual angina.  she is being admitted with unstable angina post stent.,past medical history: , longstanding hypertension, cad as above, hyperlipidemia, and overactive bladder.,medications:,1.  detrol la 2 mg once a day.,2.  prilosec for gerd 20 mg once a day.,3.  glucosamine 500/400 mg once a day for arthritis.,4.  multivitamin p.o. daily.,5.  nitroglycerin sublingual as available to her.,6.  toprol-xl 25 mg once a day which i started although she had been bradycardic, but she seems to be tolerating.,7.  aspirin 325 mg once a day.,8.  plavix 75 mg once a day.,9.  diovan 160 mg once a day.,10.  claritin 10 mg once a day for allergic rhinitis.,11.  norvasc 5 mg once a day.,12.  lipitor 5 mg once a day.,13.  evista 60 mg once a day.,allergies: , allergies to medications are none.  she denies any shrimp or sea food allergy.,family history: , her father died of an mi in his 50s and a brother had his first mi and bypass surgery at 54.,social history:  ,she does not smoke cigarettes, abuse alcohol, no use of illicit drugs.  she is divorced and lives alone and is a retired laboratory technician from cornell diagnostic laboratory.,review of systems:,  she denies a history of stroke, cancer, vomiting up blood, coughing up blood, bright red blood per rectum, bleeding stomach ulcers, renal calculi, cholelithiasis, asthma, emphysema, pneumonia, tuberculosis, home oxygen use or sleep apnea, although she has been told in the past that she snores and there was some question of apnea in 05/08.  no morning headaches or fatigue.  no psychiatric diagnosis.  no psoriasis, no lupus.  remainder of the review of systems is negative x14 systems except as described above.,physical examination:,general:  she is a pleasant elderly woman, currently in no acute distress.,vital signs:  height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees fahrenheit, blood pressure 142/70, pulse 47,  respiratory rate 16, and o2 saturation 100%,heent:  cranium is normocephalic and atraumatic.  she has moist mucosal membranes.,neck:  veins are not distended.  there are no carotid bruits.,lungs:  clear to auscultation and percussion without wheezes.,heart:  s1 and s2, regular rate.  no significant murmurs, rubs or gallops.  pmi nondisplaced.,abdomen:  soft and nondistended.  bowel sounds present.,extremities:  without significant clubbing, cyanosis or edema.  pulses grossly intact.  bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for pci and there is no evidence of hematoma or bruit and intact distal pulses.,laboratory data: , ekg reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease.,sodium 136, potassium 3.8, chloride 105, and bicarbonate 27.  bun 16 and creatinine 0.9.  glucose 110.  magnesium 2.5.  alt 107 and ast 65 and these were normal on 08/15/08.  inr is 0.89, ptt 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,impression and plan:  ,the patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery.  in any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, i am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy.  we will continue her beta-blocker and i cannot increase the dose because she is bradycardic already.  aspirin, plavix, valsartan, lipitor, and norvasc.  i am going to add imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out mi, although there is a little suspicion.  i suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect.  my concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal lv function.  she will continue the glucosamine for her arthritis, claritin for allergies, and detrol la for urinary incontinence.,total patient care time in the emergency department 75 minutes.  all this was discussed in detail with the patient and her daughter who expressed understanding and agreement.  the patient desires full resuscitation status.",2
"preoperative diagnoses:,1.  chronic cholecystitis.,2.  cholelithiasis.,postoperative diagnoses:,1.  chronic cholecystitis.,2.  cholelithiasis.,3.  liver cyst.,procedures performed:,1.  laparoscopic cholecystectomy.,2.  excision of liver cyst.,anesthesia:  ,general endotracheal and injectable 0.25% marcaine with 1% lidocaine.,specimens: , include,1.  gallbladder.,2.  liver cyst.,estimated blood loss: , minimal.,complications: , none.,operative findings:,  exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  additionally, there was a notable liver cyst.  the remainder of the abdomen remained free of any adhesions.,brief history: , this is a 66-year-old caucasian female who presented to abcd general hospital for an elective cholecystectomy.  the patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  she had had multiple attacks in the past of these complaints.  she was discovered to have had right upper quadrant pain on examination.  additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  the patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  she was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,operative procedure:  ,the patient was brought to the operative suite and placed in the supine position.  the patient received preoperative antibiotics with kefzol.  the abdomen was prepped and draped in the normal sterile fashion with betadine solution.  the patient did undergo general endotracheal anesthesia.  once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  utilizing a veress needle, the veress needle was inserted intra-abdominally and was hooked to the co2 insufflation.  the abdomen was insufflated to 15 mmhg.  after adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  decision to proceed with laparoscopic cystectomy was decided.  a subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  all ports were inserted with bladed 5 mm trocar then under direct visualization.  after all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  adhesions adjacent were taken down with a maryland dissector.  once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  this helped to better delineate the cystic duct as well as the cystic artery.  utilizing maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  utilizing endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  utilizing endoscissors, the cystic duct and cystic artery were ligated.  next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  electrocautery was used to stop any bleeding encountered along the way.  the gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  no evidence of stones were visualized.  once the gallbladder was completely excised from the liver bed, an endocatch was placed and the gallbladder was inserted into endocatch and removed from the subxiphoid port.  this was sent off as an specimen, a gallstone was identified within the gallbladder.  next, utilizing copious amounts of irrigation, the abdomen was irrigated.  a small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  this was also taken and sent off as specimen.  the abdomen was then copiously irrigated until clear irrigation was identified.  all laparoscopic ports were removed under direct visualization.  the abdomen was de-insufflated.  utilizing #0 vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  all incisions were then closed with #4-0 undyed vicryl.  two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  the areas were cleaned and dried.  steri-strips were placed.  on the incisions, sterile dressing was applied.  the patient tolerated the procedure well.  she was extubated following procedure.  she is seen to tolerate the procedure well and she will follow up with dr. x within one week for a follow-up evaluation.",13
"procedures performed:,1.  left heart catheterization.,2.  bilateral selective coronary angiography.,3.  left ventriculography.,4.  right heart catheterization.,indication: , positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,procedure: , after risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  the patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  once adequate anesthesia has been obtained, a thin-walled #18 gauge argon needle was used to cannulate the right femoral artery.  a steel guidewire was inserted through the needle into the vascular lumen without resistance.  a small nick was then made in the skin.  the pressure was held.  the needle was removed over the guidewire.  next, a #6 french arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  the guidewire and dilator were then removed.  the sheath was flushed.  next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  the catheter was then guided into the left ventricle.  the guidewire and dilator were then removed.  the catheter was then flushed.  lvedp was measured and found to be favorable for a left ventriculogram.  the left ventriculogram was performed in the rao position with a single power injection of nonionic contrast material.  lvedp was then remeasured.  pullback was performed, which failed to reveal an lvao gradient.  the catheter was then removed.  next, a judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  the ostium of the left main coronary was unable to be engaged with this catheter.  thus it was removed over a guidewire.  next, a judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  left main coronary artery was then engaged.  using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  the catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  next, a judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  the guidewire was removed.  the catheter was connected to the manifold and flushed.  using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  the catheter was then removed from the ostium of the right coronary artery and then removed.  the sheath was then flushed.  because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  thus an #18 gauge argon needle was used to cannulate the right femoral vein.  a steel guidewire was inserted through the needle into the vascular lumen.  the needle was removed over the guidewire.  next, an #8 french venous sheath was advanced over the guidewire into lumen without resistance.  the guidewire and dilator were then removed.  the sheath was then flushed.  next, a swan-ganz catheter was advanced to the level of 20 cm.  the balloon was inflated.  under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  hemodynamics were measured along the way.  pa saturation, right atrial saturation, femoral artery saturation were all obtained.  once adequate study has been performed, the catheter was then removed.  both sheaths were flushed and found fine.  the patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,findings:,left ventriculogram:  ,there is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  left ventricular end-diastolic pressure was 38 mmhg preinjection and 40 mmhg postinjection.  there is no lvao.  there is no mitral regurgitation.  there is a trileaflet aortic valve noted.,left main coronary artery:  ,the left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  there is no evidence of any hemodynamically significant stenosis.,left anterior descending: , the lad is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  there is a proximal 60% to 70% stenotic lesion.  there was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,circumflex artery:  ,the circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  there is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  the first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  the third obtuse marginal branch is also small.,right coronary artery:  ,the rca is a moderate caliber vessel with minor luminal irregularities throughout.  there is no evidence of any critical disease.  the right coronary artery is the dominant right coronary vessel.,right heart findings:  ,pulmonary artery pressure equals 61/23 with a mean of 44.  pulmonary artery wedge pressure equals 32.  right ventricle pressure equals 65/24.  the right atrial pressure equals to 22.  cardiac output by fick is 4.9.  cardiac index by fick is 2.3.  hand calculated cardiac output equals 7.8.  hand calculated cardiac index equals 3.7.  on 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  femoral artery saturation equals 99.1%.  pulse oximetry is 99%.  right atrial saturation is 76.3%.  systemic blood pressure is 166/58.  body surface area equals 2.12.  hemoglobin equals 12.6.,impression:,1.  two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  normal left ventricular function with an estimated ejection fraction of 60%.,3.  biventricular overload.,4.  moderate pulmonary hypertension.,5.  there is no evidence of shunt.,plan:,1.  the patient will be admitted for iv diuresis in light of the biventricular overload.,2.  the findings of the heart catheterization were discussed in detail with the patient and the patient's family.  there is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  we will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  the patient will remain on aggressive medical regimen including ace inhibitor, aspirin, plavix, and nitrate.,4.  the patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  the patient will have an internal medicine evaluation regarding the patient's diabetic history.",2
"chief complaint:,  right ankle sprain.,history of present illness: , this is a 56-year-old female who fell on november 26, 2007 at 11:30 a.m. while at work.  she did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle.  she describes no other injury at this time.,past medical history: , hypertension and anxiety.,past surgical history: , none.,medications: , she takes lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,allergies:,  no known drug allergies.,social history: , the patient lives here locally.  she does not report any significant alcohol or illicit drug use.  she works full time.,family history:,  noncontributory.,review of systems:,pulm:  no cough, no wheezing, no shortness of breath,cv:  no chest pain or palpitations,gi:  no abdominal pain.  no nausea, vomiting, or diarrhea.,physical exam:,general appearance:  no acute distress,vital signs:  temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, o2 sat 95% on r.a.,neck:  supple.  no lymphadenopathy.  no thyromegaly.,chest:  clear to auscultation bilaterally.,heart:  regular rate and rhythm.  no murmurs.,abdomen:  non-distended, nontender, normal active bowel sounds.,extremities:  no clubbing, no cyanosis, no edema.,musculoskeletal:  the spine is straight and there is no significant muscle spasm or tenderness there.  both knees appear to be non-traumatic with no deformity or significant tenderness.  the right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender.  there is decreased range of motion and some mild ecchymosis noted around the ankle.,diagnostic data: , x-ray of the right ankle reveals no acute fracture by my observation.  radiologic interpretation is pending., ,impression:,  right ankle sprain.,plan:,1.  motrin 800 mg t.i.d.,2.  tylenol 1 gm q.i.d. as needed.,3.  walking cast is prescribed.,4.  i told the patient to call back if any problems.  the next morning she called back complaining of worsening pain and i called in some vicodin es 1-2 p.o. q.  8 hours p.r.n. pain #60 with no refills.",25
"reason for exam: , coronary artery bypass surgery and aortic stenosis.,findings: , transthoracic echocardiogram was performed of technically limited quality.  the left ventricle was normal in size and dimensions with normal lv function.  ejection fraction was 50% to 55%.  concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  left atrium is enlarged, measuring 4.42 cm.  right-sided chambers are normal in size and dimensions.  aortic root has normal diameter.,mitral and tricuspid valve reveals annular calcification.  fibrocalcific valve leaflets noted with adequate excursion.  similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  atrial and ventricular septum are intact.  pericardium is intact without any effusion.  no obvious intracardiac mass or thrombi noted.,doppler study reveals mild-to-moderate mitral regurgitation.  severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  there is also mitral stenosis.,impression:,1.  concentric hypertrophy of the left ventricle with left ventricular function.,2.  moderate mitral regurgitation.,3.  severe aortic stenosis, severe.,recommendations: , transesophageal echocardiogram is clinically warranted to assess the aortic valve area.",31
"admission diagnosis: , microinvasive carcinoma of the cervix.,discharge diagnosis: , microinvasive carcinoma of the cervix.,procedure performed: , total vaginal hysterectomy.,history of present illness: , the patient is a 36-year-old, white female, gravida 7, para 5, last period mid march, status post tubal ligation.  she had an abnormal pap smear in the 80s, which she failed to followup on until this year.  biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  she has elected definitive therapy with a total vaginal hysterectomy.  she is aware of the future need of pap smears.,past medical history: , past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,physical examination: , physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,laboratory data and diagnostic studies: , chest x-ray was clear.  discharge hemoglobin 10.8.,hospital course: , she was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  there was an incidental cystotomy at the time of the creation of the bladder flap.  this was repaired intraoperatively without difficulty.  postoperative, she did very well.  bowel and bladder function returned quickly.  she is ambulating well and tolerating a regular diet.,routine postoperative instructions given and understood.  followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,discharge medications:,  vicodin, motrin, and macrodantin at bedtime for urinary tract infection suppression.  ,discharge condition: , good.,final pathology report was free of residual disease.",9
"scleral buckle opening,the patient was brought to the operating room and appropriately identified.  general anesthesia was induced by the anesthesiologist.  the patient was prepped and draped in the usual sterile fashion.  a lid speculum was used to provide exposure to the right eye.  a 360-degree limbal conjunctival peritomy was created with westcott scissors.  curved tenotomy scissors were used to enter each of the intermuscular quadrants.  the inferior rectus muscle was isolated with a muscle hook, freed of its tenon's attachment and tied with a 2-0 silk suture.  the 3 other rectus muscles were isolated in a similar fashion.  the 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.",36
"history: , the patient is a 4-month-old who presented today with supraventricular tachycardia and persistent cyanosis.  the patient is a product of a term pregnancy that was uncomplicated and no perinatal issues are raised.  parents; however, did note the patient to be quite dusky since the time of her birth; however, were reassured by the pediatrician that this was normal.  the patient demonstrates good interval weight gain and only today presented to an outside hospital with significant duskiness, some irritability, and rapid heart rate.  parents do state that she does appear to breathe rapidly, tires somewhat with the feeding with increased respiratory effort and diaphoresis.  the patient is exclusively breast fed and feeding approximately 2 hours.  upon arrival at children's hospital, the patient was found to be in a narrow complex tachycardia with the rate in excess of 258 beats per minute with a successful cardioversion to sinus rhythm with adenosine.  the electrocardiogram following the cardioversion had demonstrated normal sinus rhythm with a right atrial enlargement, northwest axis, and poor r-wave progression, possible right ventricular hypertrophy.,family history:,  family history is remarkable for an older sibling found to have a small ventricular septal defect that is spontaneously closed.,review of systems: , a complete review of systems including neurologic, respiratory, gastrointestinal, genitourinary are otherwise negative.,physical examination:,general:  physical examination that showed a sedated, acyanotic infant who is in no acute distress.,vital signs:  heart rate of 170, respiratory rate of 65, saturation, it is nasal cannula oxygen of 74% with a prostaglandin infusion at 0.5 mcg/kg/minute.,heent:  normocephalic with no bruit detected.  she had symmetric shallow breath sounds clear to auscultation.  she had full symmetrical pulses.,heart:  there is normoactive precordium without a thrill.  there is normal s1, single loud s2, and a 2/6 continuous shunt type of murmur could be appreciated at the left upper sternal border.,abdomen:  soft.  liver edge is palpated at 3 cm below the costal margin and no masses or bruits detected.,x-rays:,  review of the chest x-ray demonstrated a normal situs, normal heart size, and adequate pulmonary vascular markings.  there is a prominent thymus.  an echocardiogram demonstrated significant cyanotic congenital heart disease consisting of normal situs, a left superior vena cava draining into the left atrium, a criss-cross heart with atrioventricular discordance of the right atrium draining through the mitral valve into the left-sided morphologic left ventricle.  the left atrium drained through the tricuspid valve into a right-sided morphologic right ventricle.  there is a large inlet ventricular septal defect as pulmonary atresia.  the aorta was malopposed arising from the right ventricle in the anterior position with the left aortic arch.  there was a small vertical ductus as a sole source of pulmonary artery blood flow.  the central pulmonary arteries appeared confluent although small measuring 3 mm in the diameter.  biventricular function is well maintained.,final impression: , the patient has significant cyanotic congenital heart disease physiologically with a single ventricle physiology and ductal-dependent pulmonary blood flow and the incidental supraventricular tachycardia now in the sinus rhythm with adequate ventricular function.  the saturations are now also adequate on prostaglandin e1.,recommendation: , my recommendation is that the patient be continued on prostaglandin e1.  the patient's case was presented to the cardiothoracic surgical consultant, dr. x.  the patient will require further echocardiographic study in the morning to further delineate the pulmonary artery anatomy and confirm the central confluence.  a consideration will be made for diagnostic cardiac catheterization to fully delineate the pulmonary artery anatomy prior to surgical intervention.  the patient will require some form of systemic to pulmonary shunt, modified pelvic shunt or central shunt as a durable source of pulmonary blood flow.  further surgical repair was continued on the size and location of the ventricular septal defect over the course of the time for consideration of possible rastelli procedure.  the current recommendation is for proceeding with a central shunt and followed then by bilateral bidirectional glenn shunt with then consideration for a septation when the patient is 1 to 2 years of age.  these findings and recommendations were reviewed with the parents via a spanish interpreter.",27
"clinical indication:,  chest pain.,interpretation: , the patient received 14.9 mci of cardiolite for the rest portion of the study and 11.5 mci of cardiolite for the stress portion of the study.,the patient's baseline ekg was normal sinus rhythm.  the patient was stressed according to bruce protocol by dr. x.  exercise test was supervised and interpreted by dr. x.  please see the separate report for stress portion of the study.,the myocardial perfusion spect study shows there is mild anteroseptal fixed defect seen, which is most likely secondary to soft tissue attenuation artifact.  there is, however, mild partially reversible perfusion defect seen, which is more pronounced in the stress images and short-axis view suggestive of minimal ischemia in the inferolateral wall.,the gated spect study shows normal wall motion and wall thickening with calculated left ventricular ejection fraction of 59%.,conclusion:,1.  the exercise myocardial perfusion study shows possibility of mild ischemia in the inferolateral wall.,2.  normal lv systolic function with lv ejection fraction of 59%.",31
"preoperative diagnosis: , cervical carcinoma in situ.,postoperative diagnosis: , cervical carcinoma in situ.,operation performed:,  cervical cone biopsy, dilatation & curettage.,specimens:  ,cone biopsy, endocervical curettings, endometrial curettings.,indications for procedure: , the patient recently presented with a pap smear showing probable adenocarcinoma in situ.  the patient was advised to have cone biopsy to fully assess endocervical glands.,findings: , during the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  the uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,procedure: , the patient was brought to the operating room with an iv in place.  anesthetic was administered and she was placed in the lithotomy position.  the patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  angle stitches of 0 vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  the cervix was stained with lugol's iodine solution. ,after the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  the specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  a kevorkian curette was used to obtain endocervical curettings.  the cone biopsy site was sutured using a running lock stitch of 0 vicryl suture.  upon completion of the suture placement, the endocervical canal was sounded to assure patency.  a prophylactic application of monsel's solution completed the procedure.  ,the patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  final sponge, needle, and instrument counts were.",22
"subjective:,  this 32-year-old female comes in again still having not got a primary care physician.  she said she was at dr. xyz office today for her appointment, and they cancelled her appointment because she has not gotten her project access insurance into affect.  she says that project access is trying to find her a doctor.  she is not currently on project access, and so she is here to get something for the pain in her foot.  i did notice that she went in to see dr. xyz for a primary care physician on 05/14/2004.  she said she does not have a primary care physician.  she was in here just last week and saw dr. xyz for back pain and was put on pain medicines and muscle relaxers.  she has been in here multiple times for different kinds of pain.  this pain she is having is in her foot.  she had surgery on it, and she has plates and screws.  she said she was suppose to see dr. xyz about getting some of the hardware out of it.  the appointment was cancelled, and that is why she came here.  it started hurting a lot yesterday, but she had this previous appointment with dr. xyz so she thought she would take care of it there, but they would not see her.  she did not injure her foot in any way recently.  it is chronically painful.  every time she does very much exercise it hurts more.  we have x-rayed it in the past.  she has some hardware there.  it does not appear to be grossly abnormal or causing any loosening or problems on x-ray.,physical exam: , examination of her foot shows some well-healed surgical scars.  on the top of her foot she has two, and then on the lateral aspect below her ankle she has a long scar.  they are all old, and the surgery was done over a year ago.  she is walking with a very slight limp.  there is no redness.  no heat.  no swelling of the foot or the ankle.  it is mildly tender around the medial side of the foot just inferior to the medial malleolus.  it is not warm or red.,assessment:,  foot pain.,plan:,  she has been in here before.  she seems very pleasant.  thought maybe she certainly might be having some significant pain, so i gave her some lortab 7.5 to take with a refill.  after she left, i got to thinking about it and looked into her record.  she has been in here multiple times for pain medicine.  she has a primary care physician, and now she is telling us she does not have a primary care physician even though she had seen dr. xyz not too long ago.  we called dr. xyz office.  dr. xyz nurse said that the patient did not have an appointment today.  she has an appointment on june 15, 2004, for a postop check.  they did not tell her they would not see her today because of insurance, so the patient was lying to me.  we will keep that in mind the next time she returns, because she will likely be back.  she did say that project access will be approving her insurance next week, so she will be able to see dr. xyz soon.",33
"reason for consultation: , left hip fracture.,history of present illness: , the patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight.  history was obtained from the patient.  as per the history, she reported that she has been having back pain with left leg pain since past 4 weeks.  she has been using a walker for ambulation due to disabling pain in her left thigh and lower back.  she was seen by her primary care physician and was scheduled to go for mri yesterday.  however, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall.  since then, she was unable to ambulate.  the patient called paramedics and was brought to the emergency room.  she denied any history of fall.  she reported that she stepped the wrong way causing the pain to become worse.  she is complaining of severe pain in her lower extremity and back pain.  denies any tingling or numbness.  denies any neurological symptoms.  denies any bowel or bladder incontinence.,x-rays were obtained which were remarkable for left hip fracture.  orthopedic consultation was called for further evaluation and management.  on further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago.  she underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,past medical history: , sciatica and melanoma.,past surgical history:  ,as discussed above, surgery for melanoma and hysterectomy.,allergies: , none.,social history: , denies any tobacco or alcohol use.  she is divorced with 2 children.  she lives with her son.,physical examination:,general:  the patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,musculoskeletal:  examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity.  tenderness to palpation is present.  leg rolling is positive for severe pain in the left proximal hip.  further examination of the spine is incomplete secondary to severe leg pain.  she is unable to perform a straight leg raising.  ehl/edl 5/5.  2+ pulses are present distally.  calf is soft and nontender.  homans sign is negative.  sensation to light touch is intact.,imaging:,  ap view of the hip is reviewed.  only 1 limited view is obtained.  this is a poor quality x-ray with a lot of soft tissue shadow.  this x-ray is significant for basicervical-type femoral neck fracture.  lesser trochanter is intact.  this is a high intertrochanteric fracture/basicervical.  there is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray.  we need to order repeat x-rays including ap pelvis, femur, and knee.,labs:,  have been reviewed.,assessment: , the patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,discussion and plan: , nature and course of the diagnosis has been discussed with the patient.  based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip.  at the present time, i would recommend obtaining a bone scan and repeat x-rays, which will include ap pelvis, femur, hip including knee.  she denies any pain elsewhere.  she does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture.  i have discussed the case with dr. x and recommended oncology consultation.,with the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type.  indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, dvt, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest.  she understands above and is willing to undergo further procedure.  the goal and the functional outcome have been explained.  further plan will be discussed with her once we obtain the bone scan and the radiographic studies.  we will also await for the oncology feedback and clearance.,thank you very much for allowing me to participate in the care of this patient.  i will continue to follow up.",25
"preoperative diagnosis:  ,thyroid goiter with substernal extension on the left.,postoperative diagnosis:,  thyroid goiter with substernal extension on the left.,procedure performed:,  total thyroidectomy with removal of substernal extension on the left.,third anesthesia: , general endotracheal.,estimated blood loss: , approximately 200 cc.,complications: , none.,indications for procedure:,  the patient is a 54-year-old caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine.  the patient subsequently then had a ct scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch.  the patient was then immediately set up for surgery.  after risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,procedure:,  the patient was brought to the operative suite by anesthesia and placed on the operative table in the supine position.  the patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed.  after this, the patient then had the area marked initially.  the preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total.  after this, the patient was then prepped and draped in the usual sterile fashion.  a #15 bard-parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline.  after this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle.  there appeared to be a natural dehiscence of the platysma in the midline.  a sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, metzenbaum scissors and debakey forceps.  any bleeding was controlled with monopolar cauterization.  after this, the two anterior large jugular veins were noted and resected laterally.  the patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right.  this was grasped on either side with a debakey forceps and dissected with monopolar cauterization and dissected with a metzenbaum scissors.  after this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles.  the sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland.  after this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and kitners.  the left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly.  after this, the superior and inferior parathyroid glands were noted.  the dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly.  after this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed vicryl tie.  the superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with metzenbaum scissors.  after this, the thyroid gland was further freed down to the level of the berry's ligament inferiorly and the dissection was carried once again more superiorly.  the fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective berry's ligament tissue from the gland with the bipolar cauterization and the fine stat.  finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly.  the recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to berry's ligament.  the middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed vicryl ties and also bipolared with the bipolar cauterization bilaterally.  the berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to pathology.  the neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  after this, surgicel was then placed in the bilateral neck regions and a #10 jackson-pratt drain was then placed within the left neck region with some extension over to the right neck region.  this was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture.  the strap muscles were then reapproximated with a running #3-0 vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed vicryl.  the skin was then reapproximated with a #5-0 prolene subcuticular along with a #6-0 fast over the top.  after this, mastisol steri-strips and bacitracin along with a sterile dressing and a __________ dressing were then placed.  the patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the jp drain.  the patient was then turned back to anesthesia, extubated in the operating room and transferred to recovery in stable condition.  the patient tolerated the procedure well and remained stable throughout.",12
"preoperative diagnosis:  ,cervical spondylosis and herniated nucleus pulposus of c4-c5.,postoperative diagnosis:,  cervical spondylosis and herniated nucleus pulposus of c4-c5.,title of operation:,  anterior cervical discectomy c4-c5 arthrodesis with 8 mm lordotic acf spacer, corticocancellous, and stabilization with synthes vector plate and screws.,estimated blood loss:,  less than 100 ml.,operative procedure in detail: , after identification, the patient was taken to the operating room and placed in supine position.  following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  a shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  a preoperative x-ray was obtained to identify the operative level and neck position.  an incision was marked at the c4-c5 level on the right side.  the incision was opened with #10 blade knife.  dissection was carried down through subcutaneous tissues using bovie electrocautery.  the platysma muscle was divided with the cautery and mobilized rostrally and caudally.  the anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  the avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  this was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  the operative level was confirmed with an intraoperative x-ray.  the longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  the anterior longitudinal ligament was then taken down with the insulated bovie electrocautery tip exposing the vertebral bodies of c4 and c5.  self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of c4 and c5, and distraction was instituted.  we then incise the annulus of c4-c5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  operating microscope was draped and brought into play.  dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  we now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  bone was then removed with 2 mm kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm kerrison punch.  there was a transligamentous disc herniation, which was removed during this process.  we then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  cord was seen to be pulsating freely behind the dura.  there appeared to be no complications and the decompression appeared adequate.  we now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the c5 vertebral body.  an 8 mm lordotic trial was used and appeared perfect.  we then used a corticocancellous 8 mm lordotic graft.  this was tapped into position.  distraction was released, appeared to be in excellent position.  we then positioned an 18 mm vector plate over the inner space.  intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  we then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  all of the screws locked to the plate and this was confirmed on visual inspection.  intraoperative x-ray was again obtained.  construct appeared satisfactory.  attention was then directed to closure.  the wound was copiously irrigated.  all of the self-retaining retractors were removed.  bleeding points were controlled with bone wax and bipolar electrocautery.  the platysma layer was now closed with interrupted 3-0 vicryl sutures.  the skin was closed with running 3-0 vicryl subcuticular stitch.  steri-strips were applied.  a sterile bandage was applied.  all sponge, needle, and cottonoid counts were reported as correct.  the patient tolerated the procedure well.  he was subsequently extubated in the operating room and transferred to pacu in satisfactory condition.",25
"s:,  abc is in today for a followup of her atrial fibrillation.  they have misplaced the cardizem.  she is not on this and her heart rate is up just a little bit today.  she does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the coumadin therapy.  she is very adamant that she wants to stop the coumadin.  she is tired of blood draws.  we have had a difficult time getting her regulated.  no chest pains.  no shortness of breath.  she is moving around a little bit better.  her arm does not hurt her.  her back pain is improving as well.,o:,  vital signs as per chart.  respirations 15.  exam:  nontoxic.  no acute distress.  alert and oriented.  heent:  tms are clear bilaterally without erythema or bulging.  clear external canals.  clear tympanic.  conjunctivae are clear.  clear nasal mucosa.  clear oropharynx with moist mucous membranes.  neck is soft and supple.  lungs are clear to auscultation.  heart is irregularly irregular, mildly tachycardic.  abdomen is soft and nontender.  extremities:  no cyanosis, no clubbing, no edema.,ekg shows atrial fibrillation with a heart rate of 104.,a:,1.",33
"preoperative diagnoses:,1.  partial rotator cuff tear with impingement syndrome.,2.  degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,postoperative diagnoses:,1.  partial rotator cuff tear with impingement syndrome.,2.  degenerative osteoarthritis of acromioclavicular joint, left shoulder.,procedure performed:,1.  arthroscopy with arthroscopic rotator cuff debridement.,2.  anterior acromioplasty.,3.  mumford procedure left shoulder.,specifications: , the entire operative procedure was done in inpatient operative suite, room #1 at abcd general hospital.  this was done in a modified beach chair position with interscalene and subsequent general anesthetic.,history and gross findings: , this is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  he was refractory to conservative outpatient therapy.  he had injection of his ac joint, which removed symptoms but was not long lasting.  after discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  all else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  the remainder of the rotator cuff observed was noted to be intact.  subacromially, the patient was noted to have increased synovitis.  degenerative changes were noted upon observation of the distal clavicle.,operative procedure: , the patient was laid supine upon the operative table.  after receiving interscalene block anesthetic by anesthesia department, the patient was placed in modified beach chair position.  he was prepped and draped in the usual sterile manner.  portals were created posteriorly and anteriorly from outside to in.  a full and complete diagnostic intraarticular arthroscopy was carried out.  debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  retrospectively it was approximately 25% of the generalized thickness.,attention was then turned to the subacromial region.  the scope was directed subacromially.  a portal was created laterally.  ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,it was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  thus, the patient was anesthetized safely and secured.  an oblique incision was carried at the cross langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  hemostasis was controlled via electrocoagulation.  flaps were created.  anterior deltoid was reflected inferiorly.  anterior acromioplasty was carried out with a saw then a micro-aire and then a beaver-tail rasp.  an excellent decompression was present.  ca ligament had been previously resected.  we then took the incision over the distal clavicle.  the end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the micro-aire saw.  the beaver-tail rasp was utilized to smooth off the edges.  pain buster catheter was placed deep to closure of the ac capsule and then to the deltoid with interrupted #1 vicryl.  transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  a superficial running #2-0 vicryl suture was utilized for deltoid closure distally.  interrupted #2-0 vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and adaptic, 4x4s, abds, and elastoplast tape placed for compression dressing.  0.25% marcaine was flooded into the joint prior to the skin closure.  pain buster catheter was hooked up.  the patient's arm was placed in arm sling.  he was safely transferred to the pacu in apparent satisfactory condition.  expected surgical prognosis on this patient is fair.",25
"clinical indications: , mrsa bacteremia, rule out endocarditis.  the patient has aortic stenosis.,description of procedure: , the transesophageal echocardiogram was performed after getting verbal and a written consent signed.  then a multiplane tee probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  there were no complications.  the patient's throat was numbed with cetacaine spray and iv sedation was achieved with versed and fentanyl.,findings:,1.  aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  the peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmhg and peak gradient 84 mmhg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  mitral valve is calcified and thick.  no vegetation seen.  there is mild-to-moderate mr present.  there is mild ai present also.,3.  tricuspid valve and pulmonary valve are structurally normal.,4.  there is a mild tr present.,5.  there is no clot seen in the left atrial appendage.  the velocity in the left atrial appendage was 0.6 m/sec.,6.  intraatrial septum was intact.  there is no clot or mass seen.,7.  normal lv and rv systolic function.,8.  there is thick raised calcified plaque seen in the thoracic aorta and arch.,summary:,1.  there is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  calculated aortic valve area was 0.6 sq. cm.,2.  normal lv systolic function.,",31
"preoperative diagnoses:,1.  left spermatocele.,2.  family planning.,postoperative diagnoses:,1.  left spermatocele.,2.  family planning.,procedure performed:,1.  left spermatocelectomy/epididymectomy.,2.  bilateral partial vasectomy.,anesthesia: , general.,estimated blood loss:,  minimal.,specimen: , left-sided spermatocele, epididymis, and bilateral partial vasectomy.,disposition:  ,to pacu in stable condition.,indications and findings: , this is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  the patient also has family status complete and desired infertility.  the patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,findings: , at this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,description of procedure:,  after informed consent was obtained, the patient was moved to the operating room.  a general anesthesia was induced by the department of anesthesia.,the patient was prepped and draped in the normal sterile fashion for a scrotal approach.  a #15 blade was used to make a transverse incision on the left hemiscrotum.  electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  the left testicle was examined.  a large spermatocele was noted.  metzenbaum scissors were used to dissect the tissue around the left spermatocele.  once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  electrocautery was used to confirm excellent hemostasis.  attention was then turned to the more proximal aspect of the cord.  the vas deferens was palpated and dissected free with metzenbaum scissors.  hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  testicle was placed back in the scrotum in appropriate anatomic position.  the dartos tissue was closed with running #3-0 vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  attention was then turned to the right side.  the vas was palpated in the scrotum.  a small skin incision was made with a #15 blade and the vas was grasped with a small allis clamp and brought into the surgical field.  a scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  two ends were hemostated with hemostats and divided with metzenbaum scissors.  lumen was coagulated with electrocautery.  silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  a #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  the patient was sent to recovery in stable condition.  he was given prescriptions for doxycycline 100 mg b.i.d., for five days and vicodin es 1 p.o. q.4h. p.r.n., pain, #30 for pain.  the patient is to followup with dr. x in seven days.",37
"cc: ,low back pain (lbp) with associated ble weakness.,hx:, this 75y/o rhm presented with a 10 day h/o progressively worsening lbp. the lbp started on 12/3/95; began radiating down the rle, on 12/6/95; then down the lle, on 12/9/95. by 12/10/95, he found it difficult to walk. on 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. he was given some nsaid and drove home. by the time he got home he had great difficulty walking due to lbp and weakness in ble, but managed to feed his pets and himself. on 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to ble weakness and lbp pain. he also had had ble numbness since 12/11/95. he was evaluated locally and an l-s-spine ct scan and l-s spine x-rays were ""negative."" he was then referred to uihc.,meds: ,slntc, coumadin 4mg qd, propranolol, procardia xl, altace, zaroxolyn.,pmh: ,1) mi 11/9/78, 2) cholecystectomy, 3) turp for bph 1980's, 4) htn, 5) amaurosis fugax, od, 8/95 (mayo clinic evaluation--tee (-), but carotid doppler (+) but ""non-surgical"" so placed on coumadin).,fhx:, father died age 59 of valvular heart disease. mother died of dm. brother had cabg 8/95.,shx:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,exam:, bp130.56, hr68, rr16, afebrile.,ms: a&o to person, place, time. speech fluent without dysarthria. lucid. appeared uncomfortable.,cn: unremarkable.,motor: 5/5 strength in bue. lower extremity strength: hip flexors & extensors 4-/4-, hip abductors 3+/3+, hip adductors 5/5, knee flexors & extensors 4/4-, ankle flexion 4-/4-, tibialis anterior 2/2-, peronei 3-/3-. mild atrophy in 4 extremities. questionable fasciculations in ble. spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). no rigidity and essential normal muscle tone on passive motion.,sensory: decreased vibratory sense in stocking distribution from toes to knees in ble (worse on right). no sensory level. pp/lt/temp testing unremarkable.,coord: normal fnf-ram. slowed hks due to weakness.,station: no pronator drift. romberg testing not done.,gait: unable to stand.,reflexes: 2/2 bue. 1/trace patellae, 0/0 achilles. plantar responses were flexor, bilaterally. abdominal reflex was present in all four quadrants. anal reflex was illicited from all four quadrants. no jaw jerk or palmomental reflexes illicited.,rectal: normal rectal tone, guaiac negative stool.,gen exam: bilateral carotid bruits, no lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,course: ,wbc 11.6, hgb 13.4, hct 38%, plt 295. esr 40 (normal 0-14), crp 1.4 (normal <0.4), inr 1.5, ptt 35 (normal), creatinine 2.1, ck 346. ekg normal. the differential diagnosis included amyotrophy, polymyositis, epidural hematoma, disc herniation and guillain-barre syndrome. an mri of the lumbar spine was obtained, 12/13/95. this revealed an l3-4 disc herniation extending inferiorly and behind the l4 vertebral body. this disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. the patient underwent a l3-4 laminectomy and diskectomy and subsequently improved. he was never seen in follow-up at uihc.",25
"final diagnosis/reason for admission:,1.  acute right lobar pneumonia.,2.  hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  elevated liver function tests, etiology undetermined.,5.  the patient has a history of moderate-to-severe dementia, alzheimer's type.,6.  anemia secondary to current illness and possible iron deficiency.,7.  darkened mole on the scalp, status post skin biopsy, pending pathology report.,operation and procedure: , the patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  dr. x performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  dr. y's results pending.,disposition: , the patient discharged to long-term acute facility under the care of dr. z.,condition on discharge: , clinically improved, however, requiring acute care.,current medications:  ,include those on admission combined with iv flagyl 500 mg every 8 hours and levaquin 500 mg daily.,hospital summary: , this is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  her symptoms progressed and she presented to the emergency room at brighton gardens where a chest x-ray revealed evolving right lobar infiltrate.  she was started on antibiotics.  infectious disease was consulted.  she was initially begun on vancomycin.  blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  she was switched to iv levaquin and received iv flagyl for possible c. diff colitis as well as possible cholecystitis.  during her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  her systolic blood pressure was 60-70 mmhg despite rather aggressive iv fluid management up to 250 ml an hour.  she was seen in consultation by dr. y who monitored her fluid and pulmonary treatment.  due to some elevated liver function tests, she was seen in consultation by dr. x.  an ultrasound was negative; however, she did undergo ct scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  a hida scan was performed and revealed no evidence of gallbladder dysfunction.  liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  she also was seen in consultation by infectious disease who followed her for several days and agreed with current management of antibiotics.  over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  she was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,laboratory tests: , initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  blood cultures were negative at 5 days.  sputum culture was negative.  urine culture was negative and thoracentesis culture negative at 24 hours.  the patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of gi bleeding was obtained.  her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  her pt and ptt were normal.  occult blood studies were negative for occult blood.  hepatitis b antigen was negative.  hepatitis a antibody igm was negative.  hepatitis b core igm negative, and hepatitis c core antibody was negative.  at the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her alt was 109, ast was 70, direct bilirubin was 0.2, ldh was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,at the time of discharge, the patient had improved.  she complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by dr. z.",9
"exam: , screening full-field digital mammogram.,history:,  screening examination of a 58-year-old female who currently denies complaints.  patient has had diagnosis of right breast cancer in 1984 with subsequent radiation therapy.  the patient's sister was also diagnosed with breast cancer at the age of 59.,technique: , standard digital mammographic imaging was performed.  the examination was performed with icad second look version 7.2.,comparison: , most recently obtained __________.,findings: , the right breast is again smaller than the left.  there is a scar marker with underlying skin thickening and retraction along the upper margin of the right breast.  the breasts are again composed of a mixture of adipose tissue and a moderate amount of heterogeneously-dense fibroglandular tissue.  there is again some coarsening of the right breast parenchyma with architectural distortion which is unchanged and most consistent with postsurgical and postradiation changes.  a few benign-appearing microcalcifications are present.,no dominant malignant-appearing mass lesion, developing area of architectural distortion or suspicious-appearing cluster of microcalcifications are identified.  the skin is stable.  no enlarged axillary lymph node is seen.,impression:,1.  no significant interval changes are seen.  no mammographic evidence of malignancy is identified.,2.  annual screening mammography is recommended or sooner if clinical symptoms warrant.,birads classification 2 - benign,mammography information:,1.  a certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  these images were obtained with fda-approved digital mammography equipment, and icad second look software version 7.2 was utilized.",31
"reason for consultation: , left flank pain, ureteral stone.,brief history: , the patient is a 76-year-old female who was referred to us from dr. x for left flank pain.  the patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  the patient has had pain in the abdomen and across the back for the last four to five days.  the patient has some nausea and vomiting.  the patient wants something done for the stone.  the patient denies any hematuria, dysuria, burning or pain.  the patient denies any fevers.,past medical history: , negative.,past surgical history:  ,years ago she had surgery that she does not recall.,medications: , none.,allergies: , none.,review of systems: , denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  the patient does have a history of nausea and vomiting, but is doing better.,physical examination:,vital signs:  the patient is afebrile.  vitals are stable.,heart:  regular rate and rhythm.,abdomen:  soft, left-sided flank pain and left lower abdominal pain.,the rest of the exam is benign.,laboratory data: , white count of 7.8, hemoglobin 13.8, and platelets 234,000.  the patient's creatinine is 0.92.,assessment:,1.  left flank pain.,2.  left ureteral stone.,3.  nausea and vomiting.,plan: , plan for laser lithotripsy tomorrow.  options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  the patient has a pretty enlarged stone.  failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  the patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  the patient understood all the risk, benefits of the procedure and wanted to proceed.  need for stent was also discussed with the patient.  the patient will be scheduled for surgery tomorrow.  plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for kub to evaluate for the exact location of the stone prior to surgery tomorrow.",37
"preoperative diagnosis: , tailor's bunion, right foot.,postoperative diagnosis: , tailor's bunion, right foot.,procedure: , closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,anesthesia: , local infiltrate with iv sedation.,indications for surgery: , the patient has had a longstanding history of foot problems.  the problem has been progressive in nature.  the preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed.  the patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered.  the patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity.  the purpose of the surgery is to alleviate pain and discomfort.,details of procedure:  ,the patient was given 1 g of ancef iv for antibiotic prophylaxis 30 minutes prior to the procedure.  the patient was brought to the operating room and placed in the supine position.  no tourniquet was utilized.  iv sedation was achieved followed by a local anesthetic consisting of approximately 10 ml total in 1:1 mixture of 0.25% marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  the lower extremity was prepped and draped in the usual sterile manner.  balanced anesthesia was obtained.,procedure:, closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.  a dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal.  care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery.  the extensor tendon was identified and retracted medially.  sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer.  a linear periosteal capsular incision was made in line with the skin incision.  the capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface.  inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head.  an oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration.  the both edges were rasped smooth.,attention was then focused on the fifth metatarsal.  the periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface.  an excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal.  generous amounts of lateral cortex were preserved for the lateral hinge.  the wedge was removed from the surgical field.  the fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position.  good purchase was noted at the osteotomy site.  inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position.  the surgical site was flushed with copious amounts of normal saline irrigation.  the periosteal and capsular layers were closed with running sutures of 3-0 vicryl.  the subcutaneous tissues were closed with 4-0 vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion.  a dressing consisting of adaptic, 4 x 4, confirming bandages, and ace wrap to provide mild compression was applied.  the patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,a walker boot was dispensed and applied.  the patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,office visit will be in 4 days.  the patient was given prescriptions for keflex 500 mg one p.o. t.i.d. for 10 days and ultram er, #15 one p.o. daily along with written and oral home instructions including a number on which i can be reached 24 hours a day if any problem arises.,after short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.",36
"preoperative diagnoses: , papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,postoperative diagnoses: , papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,procedure:  ,the patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,findings: , normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,estimated blood loss:  ,approximately 10 ml.,fluids: , crystalloid only.,complications: , none.,drains: , rubber band drain in the neck.,condition:,  stable.,procedure:  ,the patient placed supine under general anesthesia.  first, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and betadine prep.  sterile dressing was placed.  the laryngeal monitoring was noted to be working fine.  then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  the strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  then, using bipolar cautery and a coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the berry ligaments.  the berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the harmonic scalpel and removed.  no bleeding was seen.  there was a small nick in the external jugular vein that was tied with a 4-0 vicryl suture ligature.  after this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  after this was completed, no bleeding was seen.  the laryngeal nerve could be seen and intact and then rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and mastisol and steri-strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  procedure was then terminated at that time.",12
"preoperative diagnosis:,  bladder lesions with history of previous transitional cell bladder carcinoma.,postoperative diagnosis: , bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,operation performed:  ,cystoscopy, bladder biopsies, and fulguration.,anesthesia: , general.,indication for operation: , this is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  he was treated for a large transitional cell carcinoma of the bladder with turbt in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  he has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  recent cystoscopy raises suspicion of another recurrence.,operative findings: , the entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  scarring was noted along the base of the bladder from the patient's previous cysto turbt.  ureteral orifice on the right side was not able to be identified.  the left side was unremarkable.,description of operation: , the patient was taken to the operating room.  he was placed on the operating table.  general anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  the genitalia and lower abdomen were prepared with betadine and draped subsequently.  the urethra and bladder were inspected under video urology equipment (25 french panendoscope) with the findings as noted above.  cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  each of these biopsy sites were fulgurated with bugbee electrodes.  inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  the patient's bladder was then emptied.  cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  there were no apparent complications, and the patient appeared to tolerate the procedure well.  estimated blood loss was less than 15 ml.",36
"history of present illness: , the patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and i was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall.  basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock.  when she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on cardizem with reportedly heart rate in the 50s, so that was stopped.  review of ekgs from that time shows what appears to be multifocal atrial tachycardia with followup ekg showing wandering atrial pacemaker.  an ecg this morning showing normal sinus rhythm with frequent apcs.  her potassium at that time was 3.1.  she does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior.  she denies any chest pain nor shortness of breath prior to or since the fall.  she states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,past cardiac history: , she is followed by dr. x in our office and has a history of severe tricuspid regurgitation with mild elevation and pa pressure.  on 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement.  she has previously had a persantine myoview nuclear rest-stress test scan completed at abcd medical center in 07/06 that was negative.  she has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant.  she has a history of hypertension and ekgs in our office show normal sinus rhythm with frequent apcs versus wandering atrial pacemaker.  she does have a history of significant hypertension in the past.  she has had dizzy spells and denies clearly any true syncope.  she has had bradycardia in the past from beta-blocker therapy.,medications on admission:,1.  multivitamin p.o. daily.,2.  aspirin 325 mg once a day.,3.  lisinopril 40 mg once a day.,4.  felodipine 10 mg once a day.,5.  klor-con 20 meq p.o. b.i.d.,6.  omeprazole 20 mg p.o. daily presumably for gerd.,7.  miralax 17 g p.o. daily.,8.  lasix 20 mg p.o. daily.,allergies: , penicillin.  it is listed that toprol has caused shortness of breath in her office chart and i believe she has had significant bradycardia with that in the past.,family history:,  she states her brother died of an mi suddenly in his 50s.,social history: , she does not smoke cigarettes, abuse alcohol, nor use any illicit drugs.  she is retired from morse chain and delivering newspapers.  she is widowed.  she lives alone but has family members who live either on her property or adjacent to it.,review of systems: , she denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers.  she does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use.  she does note occasional peripheral edema.  she is not aware of prior history of mi.  she denies diabetes.  she does have a history of gerd.  she notes feeling depressed at times because of living alone.  she denies rheumatologic conditions including psoriasis or lupus.  remainder of review of systems is negative times 15 except as described above.,physical exam:  ,height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, o2 saturation 97%.  on general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive.  heent:  shows cranium is  normocephalic and atraumatic.  she has moist mucosal membranes.  neck veins were not distended.  there are no carotid bruits.  lungs:  clear to auscultation anteriorly without wheezes.  she is relatively immobile because of her left hip fracture.  cardiac exam:  s1, s2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound.  there is also a soft holosystolic murmur heard.  there is no rub or gallop.  pmi is nondisplaced.  abdomen is soft and nondistended.  bowel sounds present.  extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema.  pulses appear grossly intact.  affect is appropriate.  visible skin warm and perfused.  she is not able to move because of left hip fracture easily in bed.,diagnostic studies/lab data: , pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob.  no clear pulmonary vascular congestion.  sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, bun 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06.  troponin was 0.03 followed by 0.18.  inr is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,ekgs are reviewed.  initial ekg done on 08/19/08 at 1832 shows mat, heart rate of 104 beats per minute, no ischemic changes.  she had a followup ekg done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral t-wave changes, not significantly changed from prior.  followup ekg done this morning shows normal sinus rhythm with frequent apcs.,impression:  ,she is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery.  telemetry now reviewed, shows predominantly normal sinus rhythm with frequent apcs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and i suspect that was exacerbated by prior hypokalemia, which has been corrected.  there has been no atrial fibrillation documented.  i do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath.  she actually describes feeling good exercise capacity prior to this fall.  given favorable risk to benefit ratio for needed left hip surgery, i feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that.  continued optimization of electrolytes.  the patient cannot take beta-blockers as previously toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil.  the patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery.  i do not feel any further cardiac evaluation is needed at this time and the patient may followup with dr. x after discharge.  regarding her mild thrombocytopenia, i would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.",4
"cc:, seizure d/o,hx:, 29 y/o male with cerebral palsy, non-shunted hydrocephalus, spastic quadriplegia, mental retardation, bilateral sensory neural hearing loss, severe neurogenic scoliosis and multiple contractures of the 4 extremities, neurogenic bowel and bladder incontinence, and a history of seizures.,he was seen for evaluation of seizures which first began at age 27 years, two years before presentation. his typical episodes consist of facial twitching (side not specified), unresponsive pupils, and moaning. the episodes last approximately 1-2 minutes in duration and are followed by post-ictal fatigue. he was placed on dph, but there was no record of an eeg prior to presentation. he had had no seizure events in over 1 year prior to presentation while on dph 100mg--o--200mg. he also complained of headaches for the past 10 years.,birth hx:, spontaneous vaginal delivery at 36weeks gestation to a g2p1 mother. birth weight 7#10oz. no instrumentation required. labor = 11hours. ""light gas anesthesia"" given. apgars unknown. mother reportedly had the ""flu"" in the 7th or 8th month of gestation.,patient discharged 5 days post-partum.,development: spoke first words between 1 and 2 years of age. rolled side to side at age 2, but did not walk. fed self with hands at age 2 years. never toilet trained.,pmh: ,1)hydrocephalus manifested by macrocephaly by age 2-3 months. head circumference 50.5cm at 4 months of age (wide sutures and bulging fontanels). underwent ventriculogram, age 4 months, which illustrated massive enlargement of the lateral ventricles and normal sized aqueduct and 4th ventricle. the cortex of the cerebral hemisphere was less than 1cm. in thickness; especially in the occipital regions where only a thin rim of tissue was left. neurosurgical intervention was not attempted and the patient deemed inoperable at the time. by 31 months of age the patients head circumference was 68cm, at which point the head size arrested. other problems mentioned above.,shx: ,institutionalized at age 18 years.,fhx: ,unremarkable.,exam:, vitals unknown.,ms: awake with occasional use of intelligible but inappropriately used words.,cn: rightward beating nystagmus increase on leftward gaze. right gaze preference. corneal responses were intact bilaterally. fundoscopic exam not noted.,motor: spastic quadriparesis. moves rue more than other extremities.,sensory: withdrew to pp in 4 extremities.,coord: nd,station: nd,gait: nd, wheel chair bound.,reflexes: rue 2+, lue 3+, rle 4+ with sustained cross adductor clonus in the right quadriceps. lle 3+.,other: macrocephaly (measurement not given). scoliosis. rest of general exam unremarkable except for numerous abdominal scars.,course:, eeg 8/26/92: abnormal with diffuse slowing and depressed background (left worse than right) and poorly formed background activity at 5-7hz. right posterior sharp transients, and rhythmic delta-theta bursts from the right temporal region. the findings are consistent with diffuse cerebral dysfunction and underlying seizure tendency of multifocal origin.",20
"preoperative diagnosis: , a 10-1/2 week pregnancy, spontaneous, incomplete abortion.,postoperative diagnosis:,  a 10-1/2 week pregnancy, spontaneous, incomplete abortion.,procedure: , exam under anesthesia with uterine suction curettage.,anesthesia: , spinal.,estimated blood loss: , less than 10 cc.,complications:,  none.,drains:,  none.,condition:,  stable.,indications:  ,the patient is a 29-year-old gravida 5, para 1-0-3-1, with an lmp at 12/18/05.  the patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  she began to have heavy vaginal bleeding and intense lower pelvic cramping.  she was seen in the emergency room where she was found to be hemodynamically stable.  on pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  there were bulging membranes protruding through the dilated cervix.  these symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  these findings were reviewed with her and options for treatment discussed.  she elected to proceed with an exam under anesthesia with uterine suction curettage.  the risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,procedure:  ,the patient was taken to the operating room where she was placed in the seated position.  a spinal anesthetic was successfully administered.  she was then moved to a dorsal lithotomy position.  she was prepped and draped in the usual fashion for the procedure.  after adequate spinal level was confirmed, a bimanual exam was again performed.  this revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  the previously noted cervical exam was confirmed.  the weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  this solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  the anterior cervical lip was then attached with a ring clamp.  the tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  the tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  the placental tissue was then gently tractioned out as well.  a size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  with the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  the sharp curette was then utilized to probe the endometrial surface.  a small amount of additional tissue was then felt in the posterior uterine wall.  this was curetted free.  a second pass was then made with a vacuum curette.  again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  a final pass was then made with a suction curette.,the ring clamp was then removed from the anterior cervical lip.  there was only a small amount of bleeding following the curettage.  the weighted speculum was then removed as well.  the bimanual exam was repeated and good involution was noted.  the patient was taken down from the dorsal lithotomy position.  she was transferred to the recovery room in stable condition.  the sponge and instrument count was performed and found to be correct.  the specimen of products of conception and 10-week fetus were submitted to pathology for further evaluation.  the estimated blood loss for the procedure is less than 10 ml.",36
"preoperative diagnosis: , herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,postoperative diagnosis:,  herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,procedure performed:,1.  injection for myelogram.,2.  microscopic-assisted lumbar laminectomy with discectomy at l5-s1 on the left on 08/28/03.,blood loss: , approximately 25 cc.,anesthesia: , general.,position:,  prone on the jackson table.,intraoperative findings:,  extruded nucleus pulposus at the level of l5-s1.,history: , this is a 34-year-old male with history of back pain with radiation into the left leg in the s1 nerve root distribution.  the patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  he denied any previous history of back pain or back surgeries.  because of his intractable pain as well as severe weakness in the s1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  after an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,procedure detail:  ,he was wheeled back to operating room #5 at abcd general hospital on 08/28/03.  after a general anesthetic was administered, a foley catheter was inserted.,the patient was then turned prone on the jackson table.  all of his bony prominences were well-padded.  at this time, a myelogram was then performed.  after the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  the needle was localized to the level of l3-l4 region.  once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  at this time, approximately 10 cc of conray injected into the thecal sac.  the patient was then placed in the reversed trendelenburg position in order to assist with distal migration of the contrast.  the myelogram did reveal that there was some space occupying lesion, most likely disc at the level of l5-s1 on the left.  there was a lack of space filling defect on the left evident on both the ap and the lateral projections using c-arm fluoroscopy.  at this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  a long spinal needle was then inserted into region of surgery on the right.  the surgery was going to be on the left.  once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the l5-s1 nerve root region.  at this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  at this time, a weitlaner was inserted.  bovie cautery was used to obtain hemostasis.  we further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  a cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  at this time, a taylor retractor was then inserted and held there for retraction.  suction as well as bovie cautery was used to obtain hemostasis.  at this time, a small kerrison rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the s1 nerve root, which was compressive.  we removed the extruded disc with further freeing up of the s1 nerve root.  a nerve root retractor was then placed.  identification of disc space was then performed.  a #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  a small pituitary was then inserted within the disc space and more disc material was freed and removed.  the part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,at this time, copious irrigation was used to irrigate the wound.  we then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  at this time, a small piece of gelfoam was then used to cover the exposed nerve root.  we did not have any dural leaks during this case.  #1-0 vicryl was then used to approximate the deep lumbar fascia, #2-0 vicryl was used to approximate the superficial lumbar fascia, and #4-0 running vicryl for the subcutaneous skin.  sterile dressings were then applied.  the patient was then carefully slipped over into the supine position, extubated and transferred to recovery in stable condition.  at this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.",25
"subjective:,  the patient comes back to see me today.  she is a pleasant 77-year-old caucasian female who had seen dr. xyz with right leg pain.  she has a history of prior laminectomy for spinal stenosis.  she has seen dr. xyz with low back pain and lumbar scoliosis post laminectomy syndrome, lumbar spinal stenosis, and clinical right l2 radiculopathy, which is symptomatic.  dr. xyz had performed two right l2-l3 transforaminal epidural injections, last one in march 2005.  she was subsequently seen and dr. xyz found most of her remaining symptoms are probably coming from her right hip.  an x-ray of the hip showed marked degenerative changes with significant progression of disease compared to 08/04/2004 study.  dr. xyz had performed right intraarticular hip injection on 04/07/2005.  she was last seen on 04/15/2005.  at that time, she had the hip injection that helped her briefly with her pain.  she is not sure whether or not she wants to proceed with hip replacement.  we recommend she start using a cane and had continued her on some pain medicines.,the patient comes back to see me today.  she continues to complain of significant pain in her right hip, especially with weightbearing or with movement.  she said she had made an appointment to see an orthopedic surgeon in newton as it is closer and more convenient for her.  she is taking ultracet or other the generic it sounds like, up to four times daily.  she states she can take this much more frequently as she still has significant pain symptoms.  she is using a cane to help her ambulate.,past medical history:,  essentially unchanged from her visit of 04/15/2005.,physical examination:,general:  reveals a pleasant caucasian female.,vital signs:  height is 5 feet 4 inches.  weight is 149 pounds.  she is afebrile.,heent:  benign.,neck:  shows functional range of movements with a negative spurling's.,musculoskeletal:  examination shows some mild degenerative joint disease of both knees with grade weakness of her right hip flexors and half-grade weakness of her right hip adductors and right quadriceps, as compared to the left.  straight leg raises are negative bilaterally.  posterior tibials are palpable bilaterally.,skin and lymphatics:  examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  no significant lymphadenopathy noted.,spine:  examination shows lumbar scoliosis with surgical scar with no major tenderness.  spinal movements are limited but functional.,neurological:  she is alert and oriented with appropriate mood and affect.  she has normal tone and coordination.  reflexes are 2+ and symmetrical.  sensations are intact to pinprick.,functional examination:,  gait has a normal stance and swing phase with no antalgic component to it.,impression:,1.  degenerative disk disease of the right hip, symptomatic.,2.  low back syndrome, lumbar spinal stenosis, clinically right l2 radiculopathy, stable.,3.  low back pain with lumbar scoliosis post laminectomy syndrome, stable.,4.  facet and sacroiliac joint syndrome on the right, stable.,5.  post left hip arthroplasty.,6.  chronic pain syndrome.,recommendations:,  the patient is symptomatic primarily on her right hip and is planning on seeing an orthopedic surgeon for possible right hip replacement.  in the interim, her ultracet is not quite taking care of her pain.  i have asked her to discontinue it and we will start her on tylenol #3, up to four times a day.  i have written a prescription for this for 120 tablets and two refills.  the patient will call for the refills when she needs them.  i will plan further follow up in six months, sooner if needed.  she voiced understanding and is in agreement with this plan.  physical exam findings, history of present illness and recommendations were performed with and in agreement with dr. goel's findings.",4
"preoperative diagnoses:,1.  chronic pelvic pain.,2.  endometriosis.,3.  prior right salpingo-oophorectomy.,4.  history of intrauterine device perforation and exploratory surgery.,postoperative diagnoses:,1.  endometriosis.,2.  interloop bowel adhesions.,procedure performed:,1.  total abdominal hysterectomy (tah).,2.  left salpingo-oophorectomy.,3.  lysis of interloop bowel adhesions.,anesthesia:,  general.,estimated blood loss:  ,400 cc.,fluids: , 2300 cc of lactated ringers, as well as lactated ringers for intraoperative irrigation.,urine: , 500 cc of clear urine output.,intraoperative findings: , the vulva and perineum are without lesions.  on bimanual exam, the uterus was enlarged, movable, and anteverted.  the intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  the uterus was found to be normal in size with evidence of endometriosis on the uterus.  the right ovary and fallopian tube were absent.  the left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  there was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  there were multiple interloop bowel adhesions that were filmy in nature noted.,the appendix was absent.  there did appear to be old suture in a portion of the bowel most likely from a prior procedure.,indications: , this patient is a 45-year-old african-american gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  she did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  she has tried lupron and did stop secondary to the side effects.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  she was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  an indwelling foley catheter was placed.  with the skin knife, an incision was made removing the old cicatrix.  a bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the bovie.  the rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the bovie.  the rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  the peritoneal incision was then extended superiorly and inferiorly with metzenbaum scissors with careful visualization of the bladder.  at this point, the intraabdominal cavity was manually explored and the above findings were noted.  a lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  the bowel was then packed with moist laparotomy sponges.  prior to this, the filmy adhesions leftover were taken down.  at this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 vicryl.  at this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  the posterior aspect of the peritoneum was also dissected.  at this point, the infundibulopelvic ligament was isolated and three tie of #0 vicryl was used to isolate the pedicle.  two hemostats were then placed across the pedicle and this was transected with the scalpel.  this was then suture ligated in heaney fashion.  the right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  this was then ligated with three tie of #0 vicryl.  also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  at this point, the bladder flap was further created with sharp dissection as well as the moist ray-tech to push the bladder down off the anterior portion of the cervix.,the left uterine artery was then skeletonized and a straight heaney was placed.  in a similar fashion, the contralateral uterine artery was skeletonized and straight heaney clamp was placed.  these ligaments bilaterally were transected and suture ligated in a left heaney stitch.  at this point, curved masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  straight masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 vicryl.  at this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  the roticulator was then clamped and removed and the staple line was in place.  this was found to be hemostatic.  a suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  at this point, mccall culdoplasty was performed with an #0 vicryl incorporating each uterosacral as well as the posterior peritoneum.  there did appear to be good support on palpation.  prior to this, the specimen was handed off and sent to pathology.  at this point, there did appear to be small amount of oozing at the right peritoneum.  hemostasis was obtained using a #0 vicryl in two single stitches.  good hemostasis was then obtained on the cuff as well as the pedicles.  copious irrigation was performed at this point with lactate ringers.  the round ligaments were then incorporated into the cuff bilaterally.  again, copious amount of irrigation was performed and good hemostasis was obtained.  at this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  at this point, the bowel packing as well as moist ray-tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the metzenbaum scissors with good visualization of the underlying bowel.  good hemostasis was obtained of these sites as well.  the sigmoid colon was then returned to its anatomic position and the omentum as well.  the rectus muscle was then reapproximated with two interrupted sutures of #2-0 vicryl.  the fascia was then reapproximated with #0 vicryl in a running fashion from lateral to medial meeting in the midline.  the scarpa's fascia was then closed with #3-0 plain in a running suture.  the skin was then re-approximated with #4-0 undyed vicryl in a subcuticular closure.  this was dressed with an op-site.  the patient tolerated the procedure well.  the sponge, lap, and needle were correct x2.  after the procedure, the patient was extubated and brought out of general anesthesia.  she will go to the floor where she will be followed postoperatively in the hospital.",22
"chief reason for consultation:,  evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal ekg.,history of present illness:,  this 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  during this time, patient felt extremely short of breath and dizzy.  palpitations lasted for about five to ten minutes without any recurrence.  patient also gives history of having tightness in the chest after she walks briskly up to a block.  chest tightness starts in the retrosternal area with radiation across the chest.  chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  patient gives history of having hypertension for the last two months.  patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,medications: , ,1.  astelin nasal spray.,2.  evista 60 mg daily.,3.  lopressor 25 mg daily.,4.  patient was given a sample of diovan 80 mg daily for the control of hypertension from my office.,past history:,  the patient underwent right foot surgery and c-section.,family history:,  the patient is married, has six children who are doing fine.  father died of a stroke many years ago.  mother had arthritis.,social history:, the patient does not smoke or take any drinks.  ,allergies:,  the patient is not allergic to any medications.,review of systems:,  otherwise negative.  ,physical examination: , ,general:  well-built, well-nourished white female in no acute distress. ,vital signs:  blood pressure is 160/80.  respirations 18 per minute.  heart rate 70 beats per minute.  patient weighs 133 pounds, height 64 inches.  bmi is 22.,heent:  head normocephalic.  eyes, no evidence of anemia or jaundice.  oral hygiene is good.,neck:  supple.  no cervical lymphadenopathy. carotid upstroke is good. no bruit heard over the carotid or subclavian arteries.  trachea in midline. thyroid not enlarged.  jvp flat at 45°.,chest:  chest is symmetrical on both sides, moves well with respirations.  vesicular breath sounds heard over the lung fields.  no wheezing, crepitation, or pleural friction rub heard.  ,cardiovascular system:  pmi felt in fifth left intercostal space within midclavicular line. first and second heart sounds are normal in character.  there is a ii/vi systolic murmur best heard at the apex.  there is no diastolic murmur or gallop heard.,abdomen:  soft.  there is no hepatosplenomegaly or ascites.  no bruit heard over the aorta or renal vessels.,extremities:  no pedal edema.  femoral arterial pulsations are 3+, popliteal 2+.  dorsalis pedis and posterior tibialis are 1+ on both sides.,neuro:  normal.,ekg from dr. xyz's office shows normal sinus rhythm, st and t wave changes.  lipid profile, random blood sugar, bun, creatinine, cbc, and lfts are normal.,impression:,",2
"examination: , cardiac catheterization.,procedure performed: , left heart catheterization, lv cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,indication: , syncope with severe aortic stenosis.,complications:,  none.,description of procedure: , after informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  the right groin was prepped and draped in the usual sterile fashion.  after adequate conscious sedation and local anesthesia was obtained, a 6-french sheath was placed in the right common femoral artery and a 8-french sheath was placed in the right common femoral vein.  following this, a 7.5-french swan-ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmhg.  the catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmhg.  the catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmhg.  the pulmonary arterial pressures were noted to be 31/14/21 mmhg.  following this, the catheter was removed, the sheath was flushed and a 6-french jl4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  following this, the catheter was exchanged over the guidewire for 6-french jr4 diagnostic catheter.  we were unable to cannulate the right coronary artery.  therefore, we exchanged for a williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  following this, this catheter was exchanged over a guidewire for a 6-french langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  following this, the catheters were removed.  sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-french angio-seal device.  the patient tolerated the procedure well.  there were no complications.,description of findings: , the left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  the left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  the left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  there is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  the right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  the remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  the left ventricle appears to be normal sized.  the aortic valve is heavily calcified.  the estimated ejection fraction is approximately 60%.  there was 4+ mitral regurgitation noted.  the mean gradient across the aortic valve was noted to be 33 mmhg yielding an aortic valve area of 0.89 cm2.,conclusion:,1.  moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,plan: , the patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to dr kenneth fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.",2
"the patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  she states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  she states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  however, she states she did not know that she was pregnant at this time.  she denies any abdominal pain or vaginal bleeding.  she states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,past medical history:  diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,past surgical history:,1.  gastric bypass.,2.  bilateral carpal tunnel release.,3.  laparoscopic cholecystectomy.,4.  hernia repair after gastric bypass surgery.,5.  thoracotomy.,6.  knee surgery.,medications:,1.  lexapro 10 mg daily.,2.  tramadol 50 mg tablets two by mouth four times a day.,3.  ambien 10 mg tablets one by mouth at bedtime.,allergies:  amoxicillin causes throat swelling.  avelox causes iv site swelling.,social history:  the patient denies tobacco, ethanol, or drug use.  she is currently separated from her partner who is the father of her 21-month-old daughter.  she currently lives with her parents in greenville.  however, she was visiting the estranged boyfriend in wilkesboro, this week.,gyn history:  the patient denies history of abnormal pap smears or stds.,obstetrical history:  gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  gravida 2 is current.,review of systems:  the 14-point review of systems was negative with the exception as noted in the hpi.,physical examination:,vital signs:  blood pressure 134/45, pulse 130, respirations 28.  oxygen saturation 100%.,general:  patient lying quietly on a stretcher.  no acute distress.,heent:  normocephalic, atraumatic.  slightly dry mucous membranes.,cardiovascular exam:  regular rate and rhythm with tachycardia.,chest:  clear to auscultation bilaterally.,abdomen:  soft, nontender, nondistended with positive bowel sounds.  no rebound or guarding.,skin:  normal turgor.  no jaundice.  no rashes noted.,extremities:  no clubbing, cyanosis, or edema.,neurologic:  cranial nerves ii through xii grossly intact.,psychiatric:  flat affect.  normal verbal response.,assessment and plan:  a 34-year-old caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  given the substances taken, medications are unlikely to affect the development of the fetus.  there have been no reported human anomalies associated with ambien or tramadol use.  there is, however, a 4% risk of congenital anomalies in the general population.,2.  recommend quantitative hcg and transvaginal ultrasound for pregnancy dating.,3.  recommend prenatal vitamins.,4.  the patient to follow up as an outpatient for routine prenatal care.,",11
"indication: , aortic stenosis.,procedure: , transesophageal echocardiogram.,interpretation:  ,procedure and complications explained to the patient in detail.  informed consent was obtained.  the patient was anesthetized in the throat with lidocaine spray.  subsequently, 3 mg of iv versed was given for sedation.  the patient was positioned and transesophageal probe was introduced without any difficulty.  images were taken.  the patient tolerated the procedure very well without any complications.  findings as mentioned below.,findings:,1.  left ventricle is in normal size and dimension.  normal function.  ejection fraction of 60%.,2.  left atrium and right-sided chambers are of normal size and dimension.,3.  mitral, tricuspid, and pulmonic valves are structurally normal.,4.  aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  left atrial appendage is clean without any clot or smoke effect.,6.  atrial septum intact.  study was negative.,7.  doppler study essentially benign.,8.  aorta essentially benign.,9.  aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,summary:,1.  normal left ventricular size and function.,2.  benign doppler flow pattern.,3.  aortic valve area of 1.3 cm2 planimetry.,",31
"reason for consultation: , lightheaded, dizziness, and palpitation.,history of present illness: , the patient is a 50-year-old female who came to the emergency room.  this morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope.  during the episode, the patient describes symptoms of palpitation and fluttering of chest.  she relates the heart was racing.  by the time when she came into the emergency room, her ekg revealed normal sinus rhythm.  no evidence of arrhythmia.  the patient had some cardiac workup in the past, results are as mentioned below.  denies any specific chest pain.  activities fairly stable.  she is actively employed.  no other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage.,coronary risk factors: , no history of hypertension or diabetes mellitus.  nonsmoker.  cholesterol normal.  no history of established coronary artery disease and family history noncontributory.,family history: , nonsignificant.,surgical history: , tubal ligation.,medications: , on pain medications, ibuprofen.,allergies:,  sulfa.,personal history: , she is a nonsmoker.  does not consume alcohol.  no history of recreational drug use.,past medical history: , history of chest pain in the past.  had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal.  subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal.  an echocardiogram at that time was also normal.  at this time, presentation with lightheaded, dizziness, and palpitation.,review of systems:,constitutional:  no history of fever, rigors, or chills.,heent:  no history of cataract, blurry vision, or glaucoma.,cardiovascular:  as above.,respiratory:  shortness of breath.  no pneumonia or valley fever.,gastrointestinal:  no epigastric discomfort, hematemesis or melena.,urological:  no frequency or urgency.,musculoskeletal:  nonsignificant.,neurological:  no tia.  no cva.  no seizure disorder.,endocrine/hematologic:  nonsignificant.,physical examination:,vital signs:  pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute.,heent:  atraumatic and normocephalic.,neck:  neck veins flat.  no carotid bruits.  no thyromegaly.  no lympyhadenopathy.,lungs:  air entry bilaterally fair.,heart:  pmi normal.  s1 and s2 regular.,abdomen:  soft and nontender.  bowel sounds present.,extremities:  no edema.  pulses palpable.  no clubbing or cyanosis.,cns:  benign.,psychological:  normal.,musculoskeletal:  nonsignificant.,ekg: , normal sinus rhythm, incomplete right bundle-branch block.,laboratory data:,  h&h stable.  bun and creatinine within normal limits.  cardiac enzyme profile negative.  chest x-ray unremarkable.,impression:,1.  lightheaded, dizziness in a 50-year-old female.  no documented arrhythmia with the symptoms of palpitation.,2.  normal cardiac structure by echocardiogram a year and half ago.,3.  normal cardiac catheterization in 11/07.,4.  negative workup so far for acute cardiac event in terms of ekg, cardiac enzyme profile.",4
"preoperative diagnosis: , anemia.,procedure:,  upper gastrointestinal endoscopy.,postoperative diagnoses:,1.  severe duodenitis.,2.  gastroesophageal junction small ulceration seen.,3.  no major bleeding seen in the stomach.,procedure in detail: , the patient was put in left lateral position.  olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, ge junction, and some intermittent bleeding was seen at the ge junction.  advanced into the upper part of the stomach into the antrum.  the duodenum showed extreme duodenitis and the scope was then brought back.  retroflexion was performed, which was normal.  scope was then brought back slowly.  duodenitis was seen and a little bit of ulceration seen at ge junction.,finding: , severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.",13
"history of present illness:  ,the patient comes in today because of feeling lightheaded and difficulty keeping his balance.  he denies this as a spinning sensation that he had had in the past with vertigo.  he just describes as feeling very lightheaded.  it usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position.  it tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over.  lorazepam did not help this sensation.  his blood pressure has been up lately and his dose of metoprolol was increased.  they feel these symptoms have gotten worse since metoprolol was increased.,past medical history: , detailed on our h&p form.  positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in may of 2005, congestive heart failure, cabg, and cataract removed right eye.,current medications: , detailed on the h&p form.,physical examination: , his blood pressure sitting down was 180/80 with a pulse rate of 56.  standing up blood pressure was 160/80 with a pulse rate of 56.  his general exam and neurological exam were detailed on our h&p form.  pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,impression and plan:  ,this lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past.  he states this is more of a lightheaded type feeling.  he did have a mild blood pressure drop here in the office.  we are also concerned that bradycardia might be contributing to his feeling of lightheadedness.  we are going to suggest that he gets a holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,we will schedule him for the holter monitor and refer him back to his cardiologist.",4
"exam: , ct head without contrast, ct facial bones without contrast, and ct cervical spine without contrast.,reason for exam:,  a 68-year-old status post fall with multifocal pain.,comparisons: , none.,technique: , sequential axial ct images were obtained from the vertex to the thoracic inlet without contrast.  additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,interpretations:,head:,there is mild generalized atrophy.  scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  there are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  other differential considerations include cortical calcifications, which are less likely.  the brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  the visualized paranasal sinuses and mastoid air cells are clear.  the bony calvarium and skull base are unremarkable.,facial bones:,the osseous structures about the face are grossly intact without acute fracture or dislocation.  the orbits and extra-ocular muscles are within normal limits.  there is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  the remaining visualized paranasal sinuses and mastoid air cells are clear.  diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,cervical spine:,there is mild generalized osteopenia.  there are diffuse multilevel degenerative changes identified extending from c4-c7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  the remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  the central canal is grossly patent.  the pedicles and posterior elements appear intact with multifocal facet degenerative changes.  there is no prevertebral or paravertebral soft tissue masses identified.  the atlanto-dens interval and dens are maintained.,impression:,1.subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  there is no associated shift or mass effect at this time.  less likely, this finding could be secondary to cortical calcifications.  the patient may benefit from a repeat ct scan of the head or mri for additional evaluation if clinically indicated.,2.atrophy and chronic small vessel ischemic changes in the brain.,3.ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.findings were discussed with dr. x from the emergency department at the time of interpretation.",31
"procedure:,:  after informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  general endotracheal anesthesia was induced.  the patient was then prepped and draped in the usual sterile fashion.  an #11 blade scalpel was used to make a small infraumbilical skin incision in the midline.  the fascia was elevated between two ochsner clamps and then incised.  a figure-of-eight stitch of 2-0 vicryl was placed through the fascial edges.  the 11-mm port without the trocar engaged was then placed into the abdomen.  a pneumoperitoneum was established.  after an adequate pneumoperitoneum had been established, the laparoscope was inserted.  three additional ports were placed all under direct vision.  an 11-mm port was placed in the epigastric area.  two 5-mm ports were placed in the right upper quadrant.  the patient was placed in reverse trendelenburg position and slightly rotated to the left.  the fundus of the gallbladder was retracted superiorly and laterally.  the infundibulum was retracted inferiorly and laterally.  electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder.  the triangle of calot was carefully opened up.  the cystic duct was identified heading up into the base of the gallbladder.  the cystic artery was also identified within the triangle of calot.  after the triangle of calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder.  the cystic artery was clipped twice proximally and once distally.  scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided.  an intraoperative cholangiogram was obtained.  this revealed good flow through the cystic duct and into the common bile duct.  there was good flow into the duodenum without any filling defects.  the hepatic radicals were clearly visualized.  the cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct.  the cystic duct was then divided using scissors.  the gallbladder was then removed up away from the liver bed using electrocautery.  the gallbladder was easily removed through the epigastric port site.  the liver bed was then irrigated and suctioned.  all dissection areas were inspected.  they were hemostatic.  there was not any bile leakage.  all clips were in place.  the right gutter up over the edge of the liver was likewise irrigated and suctioned until dry.  all ports were then removed under direct vision.  the abdominal cavity was allowed to deflate.  the fascia at the epigastric port site was closed with a stitch of 2-0 vicryl.  the fascia at the umbilical port was closed by tying the previously placed stitch.  all skin incisions were then closed with subcuticular sutures of 4-0 monocryl and 0.25% marcaine with epinephrine was infiltrated into all port sites.  the patient tolerated the procedure well.  the patient is currently being aroused from general endotracheal anesthesia.  i was present during the entire case.",36
"adenoidectomy,procedure:,  the patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  following this the patient was draped in standard fashion.  the crowe-davis mouth gag was inserted in the oral cavity.  the palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  the adenoid pad was removed without difficulty.  the nasopharynx was packed.  following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  the crowe-davis was released.,the patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.",36
"subjective:,  i am asked to see the patient today with ongoing issues around her diabetic control.  we have been fairly aggressively, downwardly adjusting her insulins, both the lantus insulin, which we had been giving at night as well as her sliding scale humalog insulin prior to meals.  despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her lantus insulin from around 84 units down to 60 units, which is a considerable change.  what i cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  the staff reports to me that her appetite is good and that she is eating as well as ever.  i talked to anna today.  she feels a little fatigued.  otherwise, she is doing well.,physical examination:  ,vitals as in the chart.  the patient is a pleasant and cooperative.  she is in no apparent distress.,assessment and plan: , diabetes, still with some problematic low blood glucoses, most notably in the morning.  to address this situation, i am going to hold her lantus insulin tonight and decrease and then change the administration time to in the morning.  she will get 55 units in the morning.  i am also decreasing once again her humalog sliding scale insulin prior to meals.  i will review the blood glucoses again next week.,",33
"preoperative diagnoses:,1.  cholelithiasis.,2.  acute cholecystitis.,postoperative diagnoses:,1.  acute on chronic cholecystitis.,2.  cholelithiasis.,procedure performed: , laparoscopic cholecystectomy with cholangiogram.,anesthesia: , general.,indications: , this is a 38-year-old diabetic hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea.  ultrasound revealed cholelithiasis.  the patient also had somewhat thickened gallbladder wall.  the patient was admitted through emergency room last night with acute onset right upper quadrant pain.  clinically, it was felt the patient had acute cholecystitis.  laparoscopic cholecystectomy with cholangiogram was advised.  procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,description of procedure: , the patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped.  a small transverse incision was made just above the umbilicus under local anesthesia.  fascia was opened vertically.  stay sutures were placed in the fascia.  peritoneal cavity was carefully entered.  hasson cannula was inserted and peritoneal cavity was insufflated with co2.,laparoscopic camera was inserted, and the patient was placed in reverse trendelenburg, rotated to the left.  a 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  examination at this time showed no free fluid, no acute inflammatory changes.  liver was grossly normal.  gallbladder was noted to be thickened.  gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,the fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated.  it was clipped distally and using c-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal.  there was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted.  it was presumed that this was probably a congenital anomaly.  the cystic duct was clipped twice proximally and divided beyond the clips.  cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,the gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port.  specimen was sent for histopathology.  subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  hemostasis was good.  trocars were removed under direct vision and peritoneal cavity was evacuated with co2.  umbilical area fascia was closed with 0-vicryl figure-of-eight sutures, required extra sutures to close the fascial defect.  some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat.  in the end, the repair appears to be quite satisfactory.  rest of the incisions closed with 3-0 vicryl for the subcutaneous tissues and staples for the skin.  sterile dressing was applied.,the patient transferred to recovery room in stable condition.",36
"exam: , ap abdomen and ultrasound of kidney.,history:,  ureteral stricture.,ap abdomen ,findings:,  comparison is made to study from month dd, yyyy.  there is a left lower quadrant ostomy.  there are no dilated bowel loops suggesting obstruction.  there is a double-j right ureteral stent, which appears in place.  there are several pelvic calcifications, which are likely vascular.  no definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  overall findings are stable versus most recent exam.,impression: , properly positioned double-j right ureteral stent.  no evidence for calcified renal or ureteral stones.,ultrasound kidneys,findings:,  the right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  there is a right renal/ureteral stent identified.  there is no perinephric fluid collection.,the left kidney demonstrates moderate-to-severe hydronephrosis.  no stone or solid masses seen.  the cortex is normal.,the bladder is decompressed.,impression:,1.  left-sided hydronephrosis.,2.  no visible renal or ureteral calculi.,3.  right ureteral stent.",31
"past medical/surgical history: , briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on advair and albuterol.  he was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  his past surgical history is only significant for left av fistula on the wrist done in 04/2008.  he still has urine output.  he has no history of blood transfusion.,personal and social history: , he is a nonsmoker.  he denies any alcohol.  no illicit drugs.  he used to work as the custodian at the nursing home, but now on disability since 03/2008.  he is married with 2 sons, ages 5 and 17 years old.,family history:,  no similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  his father is 67 years old, currently alive with asthma.  he also has one sister who has hypertension.  the rest of the 6 siblings are alive and well.,allergies: , no known drug allergies.,medications: , singulair 10 mg once daily, cardizem 365 mg once daily, coreg 25 mg once daily, hydralazine 100 mg three times a day, lanoxin 0.125 mg once daily, crestor 10 mg once daily, lisinopril 10 mg once daily, phoslo 3 tablets with meals, and advair 250 mg inhaler b.i.d.,review of systems: , significant only for asthma.  no history of chest pain normal mi.  he has hypertension.  he occasionally will develop colds especially with weather changes.  gi:  negative.  gu:  still making urine about 1-3 times per day.  musculoskeletal:  negative.  skin:  he complains of dry skin.  neurologic:  negative.  psychiatry:  negative.  endocrine:  negative.  hematology:  negative.,physical examination: , a pleasant 41-year-old african-american male who stands 5 feet 6 inches and weighs about 193 pounds.  heent:  anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  chest:  equal chest expansion.  clear breath sounds.  heart:  distinct heart sounds, regular rhythm with no murmur.  abdomen:  soft, nontender, flabby, no organomegaly.  extremities:  poor peripheral pulses.  no cyanosis and no edema.,assessment and plan:,  this is a 49-year old african-american male who was diagnosed with end-stage renal disease secondary to hypertension.  he is on hemodialysis since 02/2008.  overall, i think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  other than that, i think that he is a reasonable candidate for transplant.,i would like to thank you for allowing me to participate in the care of your patient.  please feel free to contact me if there are any questions regarding his case.",4
"chief complaint:, ""trouble breathing."",history of present illness:, a 37-year-old german woman was brought to a shock room at the general hospital with worsening shortness of breath and cough. over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. she had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. on the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. on arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. she denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. she denied any history of ivda, tattoos, or high risk sexual behavior. she did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an ivc filter had been placed in germany . she had been living in the united states for years, and had had no recent travel. she denied any occupational exposures. before the onset of her shortness of breath she had been very active and had exercised regularly.,past medical history:,  pulmonary embolism in 1997 which had been treated with thrombolysis in germany. she reported that she had been on warfarin for 6 months after her diagnosis.  recurrent venous thromboembolism in 1999 at which time an ivc filter had been placed.  psoriasis.  she denied any history of miscarriage.,past surgical history:,  ivc filter placement 1999.",2
"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.",21
"preprocedure diagnosis: , abdominal pain, diarrhea, and fever.,postprocedure diagnosis: , pending pathology.,procedures performed: , colonoscopy with multiple biopsies, including terminal ileum, cecum, hepatic flexure, and sigmoid colon.",36
"history of present illness: , she is a 28-year-old g1 at approximately 8 plus weeks presented after intractable nausea and vomiting with blood-tinged vomit starting approximately worse over the past couple of days.  this is patient's fourth trip to the emergency room and second trip for admission.,past medical history: , nonsignificant.,past surgical history: , none.,social history: , no alcohol, drugs, or tobacco.,past obstetrical history:  ,this is her first pregnancy.,past gynecological history: , not pertinent.,while in the emergency room, the patient was found to have slight low sodium, potassium slightly elevated and her alt of 93, ast of 35, total bilirubin is 1.2.  her urine was 3+ ketones, 2+ protein, and 1+ esterase, and rbc too numerous to count with moderate amount of bacteria.  h and h stable at 14.1 and 48.7.  she was then admitted after giving some phenergan and zofran iv.  as started on iv, given hydration as well as given a dose of rocephin to treat bladder infection.  she was admitted overnight, nausea and vomiting resolved to only one episode of vomiting after receiving maalox, tolerated fluids as well as p.o. food.  followup chemistry was obtained for ast, alt and we will plan for discharge if lab variables resolve.,assessment and plan:,1.  this is a 28-year-old g1 at approximately 8 to 9 weeks gestation with one hyperemesis gravidarum admit for iv hydration and followup.,2.  slightly elevated alt, questionable, likely due to the nausea and vomiting.  we will recheck for followup.",11
"history of present illness: , hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by dr. x of cardiology through most of the day.  this afternoon, when i am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a map of 52.  dr. x was again consulted from the bedside.  we agreed to try fluid boluses and then to consider neo-synephrine pressure support if this is not successful.  in addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to tahoe pacific or a long-term acute care.  other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-st-elevation mi, hypernatremia, chronic obstructive pulmonary disease, bph, atrial flutter, inferior vena cava filter, and diabetes.,physical examination,vital signs:  t-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a map of 52, heart rate is 100.,general:  the patient is much more alert appearing than my last examination of approximately 3 weeks ago.  he denies any pain, appears to have intact mentation, and is in no apparent distress.,eyes:  pupils round, reactive to light, anicteric with external ocular motions intact.,cardiovascular:  reveals an irregularly irregular rhythm.,lungs:  have diminished breath sounds but are clear anteriorly.,abdomen:  somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,extremities:  show trace edema with no clubbing or cyanosis.,neurological:  the patient is moving all extremities without focal neurological deficits.,laboratory data: , sodium 149; this is down from 151 yesterday.  potassium 3.9, chloride 114, bicarb 25, bun 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, wbc 16.5, platelets 231,000.  inr 1.4.  transaminases are continuing to trend upwards of sgot 546, sgpt 256.  also noted is a scant amount of very concentrated appearing urine in the bag.,impression: , overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,plan,1.  hypotension.  i would aggressively try and fluid replete the patient giving him another liter of fluids.  if this does not work as discussed with dr. x, we will start some neo-synephrine, but also continue with aggressive fluid repletion as i do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  increased transaminases.  presumably this is from increased congestion.  this is certainly concerning.  we will continue to follow this.  ultrasound of the liver was apparently negative.,3.  fever and elevated white count.  the patient does have a history of pneumonia and empyema.  we will continue current antibiotics per infectious disease and continue to follow the patient's white count.  he is not exceptionally toxic appearing at this time.  indeed, he does look improved from my last examination.,4.  ventilatory-dependent respiratory failure.  the patient has received a tracheostomy since my last examination.  vent management per pma.,5.  hypokalemia.  this has resolved.  continue supplementation.,6.  hypernatremia.  this is improving somewhat.  i am hoping that with increased fluids this will continue to do so.,7.  diabetes mellitus.  fingerstick blood glucoses are reviewed and are at target.  we will continue current management.  this is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  total critical care time spent today 37 minutes.",33
"clinical history: , a 68-year-old white male with recently diagnosed adenocarcinoma by sputum cytology.  an abnormal chest radiograph shows right middle lobe infiltrate and collapse.  patient needs staging ct of chest with contrast.  right sided supraclavicular and lower anterior cervical adenopathy noted on physical exam.,technique: , multiple transaxial images utilized in 10 mm sections were obtained through the chest.  intravenous contrast was administered.,findings: , there is a large 3 x 4 cm lymph node seen in the right supraclavicular region.  there is a large right paratracheal lymph node best appreciated on image #16 which measures 3 x 2 cm.  a subcarinal lymph node is enlarged also.  it measures 6 x 2 cm.  multiple pulmonary nodules are seen along the posterior border of the visceral as well as parietal pleura.  there is a pleural mass seen within the anterior sulcus of the right hemithorax as well as the right crus of the diaphragm.  there is also a soft tissue density best appreciated on image #36 adjacent to the inferior aspect of the right lobe of the liver which most likely also represents metastatic deposit.  the liver parenchyma is normal without evidence of any dominant masses.  the right kidney demonstrates a solitary cyst in the mid pole of the right kidney.,impression:,1.  greater than twenty pulmonary nodules demonstrated on the right side to include pulmonary nodules within the parietal as well as various visceral pleura with adjacent consolidation most likely representing pulmonary neoplasm.,2.  extensive mediastinal adenopathy as described above.,3.  no lesion seen within the left lung at this time.,4.  supraclavicular adenopathy.",31
"reason for consultation: , renal failure.,history of present illness:,  thank you for referring ms. abc to abcd nephrology.  as you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to xyz hospital.  she had been admitted at that time with chest pain and was subsequently transferred to university of a and had a cardiac catheterization, which did not show any coronary artery disease.  she also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  her creatinine both at xyz hospital and university of a was elevated at 2.4.  i do not have the results from the prior years.  a repeat creatinine on 08/16/06 was 2.3.  the patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  she also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  she had bladder studies a long time ago.  she complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  she also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  she denies any nonsteroidal antiinflammatory drug use.  she denies any other over-the-counter medication use.  she has chronic hypokalemia and has been on potassium supplements recently.  she is unsure of the dose.  ,past medical history: ,1.  hypertension on and off for years.  she states she has been treated intermittently but lately has again been off medications.,2.  gastroesophageal reflux disease.,3.  gastritis.,4.  hiatal hernia.,5.  h. pylori infection x3 in the last six months treated.,6.  chronic hypokalemia secondary to chronic diarrhea.,7.  recurrent admissions with nausea, vomiting, and dehydration.  ,8.  renal cysts found on a cat scan of the abdomen.,9.  no coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  stomach bypass surgery 1975 with chronic diarrhea.,11.  history of uti multiple times recently.,12.  questionable history of kidney stones.,13.  history of gingival infection secondary to chronic steroid use, which was discontinued in july 2001.,14.  depression.,15.  diffuse degenerative disc disease of the spine.,16.  hypothyroidism.,17.  history of iron deficiency anemia in the past.  ,18.  hyperuricemia.  ,19.  history of small bowel resection with ulcerative fibroid.  ,20.  occult severe gi bleed in july 2001.,past surgical history: ,  the patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck april 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor august 4, 2005.  ,current medications: ,1.  nexium 40 mg q.d.,2.  synthroid 1 mg q.d. ,3.  potassium one q.d., unsure about the dose.  ,4.  no history of nonsteroidal drug use.,allergies:",19
"procedure in detail:,  after written consent was obtained from the patient, the patient was brought back into the operating room and identified.  the patient was placed on the operating room table in supine position and given anesthetic.,once adequate anesthesia had been achieved, a careful examination of the shoulder was performed.  it revealed no patholigamentous laxity.  we then placed the patient into a beach-chair position, maintaining a neutral alignment of the head, neck, and thorax.  the shoulder was then prepped and draped in the usual sterile fashion.  we then injected the glenohumeral joint with 60 cc of sterile saline solution.  a small stab incision was made 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  through this incision, a blunt trocar was placed.,we then placed the camera through this cannula and the shoulder was insufflated with sterile saline solution.  an anterior portal was made just below the subscapularis and then we began to inspect the shoulder joint.,we found that the articular surface was in good condition.  the biceps was found to be intact.  there was a slap tear noted just posterior to the biceps.  pictures were taken.  no bankart or hill-sachs lesions were noted.  the rotator cuff was examined and there were no undersurface tears.  pictures were again taken.,we then made a lateral portal going through the muscle belly of the rotator cuff.  a drill hole was made and then knotless suture anchor was placed to repair this.  pictures were taken.  we then washed out the joint with copious amounts of sterile saline solution.  it was drained.  our 3 incisions were closed using 3-0 nylon suture.  a pain pump catheter was introduced into the shoulder joint.  xeroform, 4 x 4s, abds, tape, and sling were placed.,the patient was successfully taken out of the beach-chair position, extubated and brought to the recovery room in stable condition.  i then went out and spoke with the patient's family, going over the case, postoperative instructions, and followup care.",36
"preoperative diagnosis: , low back syndrome - low back pain.,postoperative diagnosis: , same.,procedure:,1.  bilateral facet arthrogram at l34, l45, l5s1.,2.  bilateral facet injections at l34, l45, l5s1.,3.  interpretation of radiograph.,anesthesia:  ,iv sedation with versed and fentanyl.,estimated blood loss: , none.,complications:  ,none.,indication: , pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,summary of procedure: , the patient was admitted to the or, consent was obtained and signed.  the patient was taken to the operating room and was placed in the prone position.  monitors were placed, including ekg, pulse oximeter and blood pressure monitoring.  prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, ekg, respiration and heart rate and at intervals of three minutes for blood pressure.  after adequate iv sedation with versed and fentanyl the procedure was begun.,the lumbar sacral regions were prepped and draped in sterile fashion with betadine prep and four sterile towels.,the facets in the lumbar regions were visualized with fluoroscopy using an anterior posterior view.  a skin wheal was placed with 1% lidocaine at the l34 facet region on the left.  under fluoroscopic guidance a 22 gauge spinal needle was then placed into the l34 facet on the left side.  this was performed using the oblique view under fluoroscopy to the enable the view of the ""scotty dog,"" after obtaining the ""scotty dog"" view the joints were easily seen.  negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  after negative aspiration was verified, 1/8th of a cc of omnipaque 240 dye was then injected.  negative aspiration was again performed and 1/2 cc of solution (solution consisting of 9 cc of 0.5% marcaine with 1 cc of triamcinolone) was then injected into the joint.  the needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  the 22-gauge needle was then removed.  pressure was place over the puncture site for approximately one minute.  this exact same procedure was then repeated along the left-sided facets at l45, and l5s1.  this exact same procedure was then repeated on the right side.  at each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,the patient was noted to have tolerated the procedure well without any complications.,interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, l34, l45, and l5s1.  visualizing the ""scotty dog"" technique under fluoroscopy facilitated this.  dye spread into each joint space is visualized.  no venous or arterial run-off is noted.  no epidural run-off is noted.  the joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.",36
"reason for visit:  ,this is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by dr. x. she is accompanied by her daughter.,history of present illness:,  the patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  she is not able to use the walker because her left arm is so weak.  she has not been having any headaches.  she has had a significant decrease in appetite.  she is known to have lung cancer, but ms. wilson does not know what kind.  according to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  the last note i have to evaluate is from october 2008.  ct scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head ct, no mass lesion.  i also reviewed the mri from september 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,blood tests from 11/18/2009 demonstrate platelet count at 132 and inr of 1.0.,major findings: , the patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  she also has pain in her left arm and hand at a level of 8-9/10.,vital signs: , blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,i screened the patient with questions to determine whether it is likely she has abnormal csf pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,procedure:,  lumbar puncture, diagnostic (cpt 62270).,preoperative diagnosis: , possible csf malignancy.,postoperative diagnosis:  ,to be determined after csf evaluation.,procedure performed: , lumbar puncture.,anesthesia: , local with 2% lidocaine at the l4-l5 level.,specimen removed:  ,15 cc of clear csf.,estimated blood loss: , none.,description of the procedure:  ,i explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  the patient' daughter remained present throughout the procedure.  the patient provided written consent and her daughter signed as witness to the consent.,i located the iliac crest and spinous processes before the procedure and determined the level i planned for the puncture.  during the procedure, i spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  the skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  using local anesthetic and aseptic technique, i inserted a 20-gauge spinal needle at the l4-l5 interspace and 15 cc of csf was collected without difficulty.,the patient tolerated the procedure well.,assessment:  ,white blood cells 1, red blood cells 54, glucose 59, protein 51, gram stain negative, bacterial culture negative after three days, and remaining tests pending.",36
"procedure: , esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,indications for procedure: , a 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  currently, he has a fistula from his anterior abdominal wall out.  it does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  ct scans show thickened terminal ileum, which suggest that we are dealing with crohn's disease.  endoscopy is being done to evaluate for crohn's disease.,medications:  ,general anesthesia.,instrument:,  olympus gif-160 and pcf-160.,complications: , none.,estimated blood loss:,  less than 5 ml.,findings: , with the patient in the supine position, intubated under general anesthesia.  the endoscope was inserted without difficulty into the hypopharynx.  the scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  lower esophageal sphincter was located at 40 cm from the central incisors.  it appeared normal and appeared to function normally.  the endoscope was advanced into the stomach, which was distended with excess air.  rugal folds were flattened completely.  there were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with crohn's involvement of the stomach.  the endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  two additional biopsies were obtained in the antrum for clo testing.  excess air was evacuated from the stomach.  the scope was removed from the patient who tolerated that part of the procedure well.,the patient was turned and scope was changed for colonoscopy.  prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  the colonoscope was then inserted into the anal verge.  the colonic clean out was excellent.  the scope was advanced without difficulty to the cecum.  the cecal area had multiple ulcers with exudate.  the ileocecal valve was markedly distorted.  biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  the colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  no fistulas were noted in the colon.  excess air was evacuated from the colon.  the scope was removed.  the patient tolerated the procedure well and was taken to recovery in satisfactory condition.,impression: , normal esophagus and duodenum.  there were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  all these findings are consistent with crohn's disease.,plan:  ,begin prednisone 30 mg p.o. daily.  await ppd results and chest x-ray results, as well as cocci serology results.  if these are normal, then we would recommend remicade 5 mg/kg iv infusion.  we would start modulon 50 ml/h for 20 hours to reverse the malnutrition state of this boy.  check cmp and phosphate every monday, wednesday, and friday for receding syndrome noted by following potassium and phosphate.  we will discuss with dr. x possibly repeating the ct fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  he will need an upper gi to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  if he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with crohn's in the small intestine that we cannot visualize with endoscopy.",36
"preoperative diagnosis:  large juxtarenal abdominal aortic aneurysm.,postoperative diagnosis:  large juxtarenal abdominal aortic aneurysm.,anesthesia:  general endotracheal anesthesia.,operative time:  three hours.,anesthesia time:  four hours.,description of procedure:  after thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity iv access and radial a-line, general endotracheal anesthesia was induced.  a foley catheter was placed and a right internal jugular central line was placed.  the chest, abdomen, both groin, and perineum were prepped widely with betadine and draped as a sterile field with an ioban drape.  a long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  a sterile omni-tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  with the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,the transverse colon retracted superiorly.  the small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  the posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of treitz thoroughly ligating and dividing the inferior mesenteric vein.  dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  the mid left renal artery was likewise identified.  the perirenal aorta was prepared for clamp superior to the inferior left renal artery.  during this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  the distal dissection was then completed exposing each common iliac artery.  the arteries were suitable for control.,the patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  the aneurysm was repaired.,first, the common carotid arteries were controlled with atraumatic clamps.  the inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  the aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  there was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  the vessel was controlled with a microvascular clamp.  two pairs of lumbar arteries were oversewn with 2-0 silk.  a 14 mm hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 prolene suture.  at the completion of anastomosis three patch stitches of 3-0 prolene were required for hemostasis.  the graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 prolene suture.  prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  the distal anastomosis was competent without leak.,the patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  the back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  the colon was normal in appearance and this vessel was oversewn using 2-0 silk.  the aneurysm sac was then closed about the grafts snuggly using 3-0 pds in a vest-over-pants fashion.  the posterior peritoneum was reapproximated using running 3-0 pds.  the entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the sma normal appearance of the entire viscera.  the ng tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  the midline fascia was then reapproximated using running #1 pds suture.  the subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  the skin edges coapted using surgical staples.,at the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.",13
"history: , the patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia.  mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%.  the patient was then sent to hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen.  she was also noted to have periodic breathing.  the patient is breast and bottle-fed and has been feeding well.  there has been no diarrhea or vomiting.  voiding well.  bowels have been regular.,according to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of im ampicillin.,the patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat c-section.  birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa.  the patient's mother apparently went into labor and then underwent a cesarean section.,family history: , positive for asthma and diabetes and there is no exposure to second-hand smoke.,physical examination: , ,vital signs:  the patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,general:  the patient is icteric, well hydrated.  does have periodic breathing.  color is pink and also icterus is noted, scleral and skin.,heent:  normal.,neck:  supple.,chest:  clear.,heart:  regular with a soft 3/6 murmur.  femorals are well palpable.  cap refill is immediate,abdomen:  soft, small, umbilical hernia is noted, which is reducible.,external genitalia:  those of a female child.,skin:  color icteric.  nonspecific rash on the body, which is sparse.  the patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,extremities:  the patient moves all extremities well.  has a normal tone and a good suck.,emergency department course: , it was indicated to the parents that i would be repeating labs and also catheterize urine specimen.  parents were made aware of the fact that child did have a murmur.  i spoke to dr. x, who suggested doing an ekg, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning.  the case was discussed with dr. y and he will be admitting this child for hyperbilirubinemia.,cbc done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos.  chemistries done showed sodium of 142 meq/l, potassium 4.5 meq/l, chloride 104 meq/l, co2 28 mmol/l, glucose 75 mg%, bun 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%.  total bilirubin was 25.4 mg, all of which was unconjugated.  crp was 0.3 mg%.  blood culture was drawn.  catheterized urine specimen was normal.  parents were kept abreast of what was going on all the time and the need for admission.  phototherapy was instituted in the er almost after the baby got to the emergency room.,impression:,  hyperbilirubinemia and heart murmur.,differential diagnoses: , considered breast milk, jaundice, abo incompatibility, galactosemia, and ventricular septal defect.",27
"reason for visit: , the patient referred by dr. x for evaluation of her possible tethered cord.,history of present illness:,  briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  the last surgery was in 03/95.  she did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring advil, motrin as well as tylenol pm.,denies any new bowel or bladder dysfunction or increased sensory loss.  she had some patchy sensory loss from l4 to s1.,medications: , singulair for occasional asthma.,findings: , she is awake, alert, and oriented x 3.  pupils equal and reactive.  eoms are full.  motor is 5 out of 5.  she was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  there is no evidence of clonus.  there is diminished sensation from l4 to s1, having proprioception.,assessment and plan: , possible tethered cord.  i had a thorough discussion with the patient and her parents.  i have recommended a repeat mri scan.  the prescription was given today.  mri of the lumbar spine was just completed.  i would like to see her back in clinic.  we did discuss the possible symptoms of this tethering.",33
"exam:,  mri head without contrast.,reason for exam: , severe headaches.,interpretation:,  imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  correlation is made with the head ct of 4/18/05.,on the diffusion sequence, there is no significant bright signal to indicate acute infarction.  there is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  there is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  there are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  there is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent ct scan.  this involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  no abnormal mass effect is identified.  there are no findings to suggest active hydrocephalus.  no abnormal extra-axial collection is identified.  there is normal flow void demonstrated in the major vascular systems.,the sagittal sequence demonstrates no chiari malformation.  the region of the pituitary/optic chiasm grossly appears normal.  the mastoids and paranasal sinuses are clear.,impression:,1.  no definite acute findings identified involving the brain.,2.  there is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  there is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  moderate to moderately advanced atrophy.",31
"history of present illness: , this is a 19-year-old known male with sickle cell anemia.  he comes to the emergency room on his own with 3-day history of back pain.  he is on no medicines.  he does live with a room mate.  appetite is decreased.  no diarrhea, vomiting.  voiding well.  bowels have been regular.  denies any abdominal pain.  complains of a slight headaches, but his main concern is back ache that extends from above the lower t-spine to the lumbosacral spine.  the patient is not sure of his immunizations.  the patient does have sickle cell and hemoglobin is followed in the hematology clinic.,allergies: , the patient is allergic to tylenol with codeine, but he states he can get morphine along with benadryl.,medications: , he was previously on folic acid.  none at the present time.,past surgical history: , he has had no surgeries in the past.,family history: , positive for diabetes, hypertension and cancer.,social history: , he denies any smoking or drug usage.,physical examination: , ,vital signs:  on examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,general:  he is alert, speaks in full sentences, he does not appear to be in distress.,heent:  normal.,neck:  supple.,chest:  clear.,heart:  regular.,abdomen:  soft.  he has pain over the mid to lower spine.,skin:  color is normal.,extremities:  he moves all extremities well.,neurologic:  age appropriate.,er course: , it was indicated to the patient that i will be drawing labs and giving him iv fluids.  also that he will get morphine and benadryl combination.  the patient was ordered a liter of ns over an hour, and was then maintained on d5 half-normal saline at 125 an hour.  cbc done showed white blood cells 4300, hemoglobin 13.1 g/dl, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dl, all of which was indirect.  the patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  he received morphine 5 mg and benadryl 25 mg.  i subsequently spoke to dr. x and it was decided to admit the patient.,the patient initially stated that he wanted to be observed in the er and given pain control and fluids and wanted to go home in the morning.  he stated that he has a job interview in the morning.  the resident service did come to evaluate him.  the resident service then spoke to dr. x and it was decided to admit him on to the hematology service for control of pain and iv hydration.  he is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,impression:  ,sickle cell crisis.,differential diagnosis: , veno-occlusive crisis, and diskitis.",15
"reason for consultation: , azotemia.,history of present illness:  ,the patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,over the past week, he has been noticing increasing shortness of breath.  he also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  his wife called paramedics and he was brought to the emergency room.,the patient has had a workup at this time which shows bilateral pulmonary infarcts.  he has been started on heparin and we are asked to see him because of increasing bun and creatinine.,the patient has no past history of any renal problems.  he feels that he has been in good health until this current episode.  his appetite has been good.  he denies swelling in his feet or ankles.  he denies chest pain.  he denies any problems with bowel habits.  he denies any unexplained weight loss.  he denies any recent change in bowel habits or recent change in urinary habits.,physical examination:,general:  a gentleman seen who appears his stated age.,vital signs:  blood pressure is 130/70.,chest:  chest expands equally bilaterally.  breath sounds are heard bilaterally.,heart:  had a regular rhythm, no gallops or rubs.,abdomen:  obese.  there is no organomegaly.  there are no bruits.  there is no peripheral edema.  he has good pulse in all 4 extremities.  he has good muscle mass.,laboratory data: , the patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, co2 of 19, a bun of 26, and a creatinine of 3.5.  on admission to the hospital, his creatinine on 6/27/2009 was 0.9.,the patient has had several studies including a cat scan of his abdomen, which shows poor perfusion to his right kidney.,impression:,1.  acute renal failure, probable renal vein thrombosis.,2.  hypercoagulable state.,3.  deep venous thromboses with pulmonary embolism.,discussion: , we are presented with a 36-year-old gentleman who has been in good health until this current event.  he most likely has a hypercoagulable state and has bilateral pulmonary emboli.  most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,interestingly, the urine protein was obtained which is not that elevated and i would suspect that it would have been higher.  unfortunately, the patient has been exposed to iv dye and my anxiety is that this too is contributing to his current problem.,the patient's urine output is about 30 to 40 ml per hour.,several chemistries have been ordered.  a triple renal scan has been ordered.,i reviewed all of this with the patient and his wife.  hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  if not and his renal failure progresses, we are looking at dialytic intervention.  both he and his wife were aware of this.  ,thank you very much for asking to see this acutely ill gentleman in consultation with you.",4
"reason for admission: , sepsis.,history of present illness:  ,the patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  in the emergency room, the patient was found to have a ct scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  the patient is unable to provide further history.  the patient's son is at the bedside and confirmed his history.  the patient was given iv antibiotics in the emergency room.  he was also given some hydration.,past medical history:,1.  history of cad.,2.  history of dementia.,3.  history of cva.,4.  history of nephrolithiasis.,allergies: , none.,medications:,1.  ambien.,2.  milk of magnesia.,3.  tylenol.,4.  tramadol.,5.  soma.,6.  coumadin.,7.  zoloft.,8.  allopurinol.,9.  digoxin.,10.  namenda.,11.  zocor.,12.  buspar.,13.  detrol.,14.  coreg.,15.  colace.,16.  calcium.,17.  zantac.,18.  lasix.,19.  seroquel.,20.  aldactone.,21.  amoxicillin.,family history:  ,noncontributory.,social history: , the patient lives in a board and care.  no tobacco, alcohol or iv drug use.,review of systems: , as per the history of present illness, otherwise unremarkable.,physical examination:,vital signs:  the patient is currently afebrile.  pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,general:  the patient is awake.  not oriented x3, in no acute distress.,heent:  pupils are equal, round, and reactive to light and accommodation.  extraocular movements are intact.  mucous membranes are dry.,neck:  supple.  no thyromegaly.  no jugular venous distention.,heart:  irregularly irregular, brady.,lungs:  clear to auscultation bilaterally anteriorly.,abdomen:  positive normoactive bowel sounds.  soft.  tenderness in the suprapubic region without rebound.,extremities:  no clubbing, cyanosis or edema in upper and lower extremities.",15
"admitting diagnoses:,1.  fever.,2.  otitis media.,3.  possible sepsis.,history of present illness:  ,the patient is a 10-month-old male who was seen in the office 1 day prior to admission.  he has had a 2-day history of fever that has gone up to as high as 103.6 degrees f. he has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  he has been taking tylenol and advil to help decrease the fevers, but the fever has continued to rise.  he was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,past medical history: , significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,physical examination: , on exam, he was moderately ill appearing and lethargic.  heent:  atraumatic, normocephalic.  pupils are equal, round, and reactive to light.  tympanic membranes were red and yellow, and opaque bilaterally.  nares were patent.  oropharynx was slightly moist and pink.  neck was soft and supple without masses.  heart is regular rate and rhythm without murmurs.  lungs showed increased workup of breathing, moderate tachypnea.  no rales, rhonchi or wheezes were noted.  abdomen:  soft, nontender, nondistended.  active bowel sounds.  neurologic exam showed good muscle strength, normal tone.  cranial nerves ii through xii are grossly intact.,laboratory findings: , he had electrolytes, bun and creatinine, and glucose all of which were within normal limits.  white blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  urinalysis was completely unremarkable.  chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,hospital course: , the patient was admitted to the hospital and allowed a clear liquid diet.  activity is as tolerates.  cbc with differential, blood culture, electrolytes, bun, and creatinine, glucose, ua, and urine culture all were ordered.  chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  pulse oximetry checks were ordered every shift and as needed with o2 ordered per nasal cannula if o2 saturations were less that 94%.  gave d5 and quarter of normal saline at 45 ml per hour, which was just slightly above maintenance rate to help with hydration.  he was given ceftriaxone 500 mg iv once daily to treat otitis media and possible sepsis, and i will add tylenol and ibuprofen as needed for fevers.  overnight, he did have his oxygen saturations drop and went into oxygen overnight.  his lungs remained clear, but because of the need for o2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  the nurses were instructed to attempt to wean o2 if possible and advance the diet.  he was doing clear liquids well and so i saline locked to help to accommodate improve the mobility with the patient.  he did well the following evening with no further oxygen requirement.  he continued to spike fevers but last fever was around 13:45 on the previous day.  at the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees f. with clear lungs.  he was given additional dose of rocephin when it was felt that it would be appropriate for him to be discharged that morning.,condition of the patient at discharge: , he was at 100% oxygen saturations on room air with no further dips at night.  he has become afebrile and was having no further increased work of breathing.,discharge diagnoses:,1.  bilateral otitis media.,2.  fever.,plan:  ,recommended discharge.  no restrictions in diet or activity.  he was continued omnicef 125 mg/5 ml one teaspoon p.o. once daily and instructed to follow up with dr. x, his primary doctor, on the following tuesday.  parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.",10
"exam: , ct cervical spine.,reason for exam: , mva, feeling sleepy, headache, shoulder and rib pain.,technique:,  axial images through the cervical spine with coronal and sagittal reconstructions.,findings:,  there is reversal of the normal cervical curvature at the vertebral body heights.  the intervertebral disk spaces are otherwise maintained.  there is no prevertebral soft tissue swelling.  the facets are aligned.  the tip of the clivus and occiput appear intact.  on the coronal reconstructed sequence, there is satisfactory alignment of c1 on c2, no evidence of a base of dens fracture.,the included portions of the first and second ribs are intact.  there is no evidence of a posterior element fracture.  included portions of the mastoid air cells appear clear.  there is no ct evidence of a moderate or high-grade stenosis.,impression: , no acute process, cervical spine.",25
"preoperative diagnosis: , facial and neck skin ptosis.  cheek, neck, and jowl lipotosis. facial rhytides.,postoperative diagnosis:,  same.,procedure: , temporal cheek-neck facelift (cpt 15825).  submental suction assisted lipectomy (cpt 15876).,anesthesia: , general.,description of procedure: , this patient is a 65-year-old female who has progressive aging changes of the face and neck.  the patient demonstrates the deformities described above and has requested surgical correction.  the procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  the patient has consented to surgery.,the patient was brought into the operating room and placed in the supine position on the operating table.  an intravenous line was started and anesthesia was maintained throughout the case.  the patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,the hair was prepared and secured with rubber bands and micropore tape along the incision line.  a marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  in addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  the incision was marked in the submental crease for the submental lipectomy and liposuction.  the incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,the areas to be operated on were injected with 1% lidocaine containing 1:100,000 epinephrine.  this provided local anesthesia and vasoconstriction.  the total of lidocaine used throughout the procedure was maintained at no more than 500mg.,submental suction assisted lipectomy: , the incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  a metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  the tunnels were enlarged with a 6mm flat liposuction cannula.,then with the wells-johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  a similar procedure was performed with the 4 mm cannula cleaning the area.  bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,a triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  a plication stitch of 3-0 vicryl was placed.,when a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  the wound was cleaned at the end, dried, and mastisol applied.  then tan micropore tape was placed for support to the entire area.,face lift: , after waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  a gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  a preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  the incision was made in the temporal area beveling parallel with the hair follicles.  (the incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),the plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  the dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  at the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,the facial flaps were then elevated with both blunt and sharp dissection with the kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  this area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  great care was taken to direct the plane of dissecting superficial to the parotid fascia or smas.  the entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  when the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  at no point were muscle fibers or major vessels or nerves encountered in the dissection.,the smas was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the scm.  the smas flap was then advanced posteriorly and superiorly.  the smas was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  the excess smas was trimmed and excised from the portion anterior to the auricle.  the smas was then imbricated with 2-0 surgidak interrupted sutures.,the area was then inspected for any bleeding points and careful hemostasis obtained.  the flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 tycron suture.  the excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  skin closure was accomplished in the hairbearing areas with 5-0 nylon in the preauricular tuft and 4-0 nylon interrupted in the post auricular area.  the pre auricular area was closed first with 5-0 dexon at the ear lobules, and 6-0 nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  the post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  the exact similar procedure was repeated on the left side.,at the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  any small amount of fluid was expressed post-auricularly.  a fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  a bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,abd padding over 4x4 gauze was used to cover the pre and post auricular areas.  this was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  the entire dressing complex was secured with a pre-formed elastic stretch wrap device.  all branches of the facial nerve were checked and appeared to be functioning normally.,the procedures were completed without complication and tolerated well.  the patient left the operating room in satisfactory condition.  a follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,the patient was released to home in satisfactory condition.",36
"preoperative diagnosis: , right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,postoperative diagnosis: , right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,procedure: , excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,anesthesia:,  axillary block plus iv sedation.,estimated blood loss:,  zero.,specimens,1.  inflammatory synovitis from the volar radial wrist area.,2.  inflammatory synovitis from the dorsal wrist area.,drains:,  none.,procedure detail: , patient brought to the operating room.  after induction of iv sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff.  routine prep and drape was employed.  patient received 1 gm of iv ancef preoperatively.  arm was exsanguinated by means of elevation of esmarch elastic tourniquet.  tourniquet inflated to 250 mmhg pressure.  hand positioned palm up in a lead hand-holder.  a longitudinal zigzag incision over the volar radial wrist mass was made.  skin was sharply incised.  careful blunt dissection was used in the subcutaneous tissue.  antebrachial fascia was bluntly dissected and incised to reveal the radial artery.  radial artery was mobilized preserving its dorsal and palmar branches.  small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery.  wrist mass was exposed by blunt dissection.  this appeared to be an inflammatory arthritic mass from the volar radial wrist capsule.  this was debrided down to the wrist capsule with visualization of the joint through a small capsular window.  after complete volar synovectomy the capsular window was closed with 4-0 mersilene figure-of-eight suture.  subcutaneous tissue was closed with 4-0 pds and the skin was closed with a running subcuticular 4-0 prolene.  forearm was pronated and c-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision.  an oblique incision overlying the radial styloid centered on the second extensor compartment was made.  skin was sharply incised.  blunt dissection was used in the subcutaneous tissue.  care was taken to identify and protect the superficial radial nerve.  blunt dissection was carried out in the extensor retinaculum.  this was incised longitudinally over the second extensor compartment.  epl tendon was identified, mobilized and released to facilitate retraction and prevent injury.  the interval between the ecrl and the ecrb was developed down to bone.  dorsal capsulotomy was made and local synovitis was identified.  this was debrided and sent as second pathologic specimen.  articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a slac pattern arthritis.  radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer.  dorsally the styloidectomy was beveled smooth and contoured with a rongeur.  final x-rays documenting the styloidectomy were obtained.  local synovitis beneath the joint capsule was debrided.  remnants of the scapholunate interosseous which was completely deteriorated were debrided.  the joint capsule was closed anatomically with 4-0 pds and extensor retinaculum was closed with 4-0 pds.  subcutaneous tissues closed with 4-0 vicryl.  skin was closed with running subcuticular 4-0 prolene.  steri-strips were applied to wound edge closure; 10 cc of 0.5% plain marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia.  a bulky gently compressive wrist and forearm bandage incorporating an ebi cooling pad were applied.  tourniquet was deflated.  good vascular color and capillary refill were seen to return to the tips of all digits.  patient discharged to the ambulatory recovery area and from there discharged home.,discharge prescriptions:,1.  keflex 500 mg tablets, #20, one po q.6h. x 5 days.,2.  vicodin, 40 tablets, one to two po q.4h. p.r.n.,3.  percocet, #20 tablets, one to two po q.3-4h. p.r.n. severe pain.",25
"chief complaint:  ,blood in toilet.,history: , ms. abc is a 77-year-old female who is brought down by way of ambulance from xyz nursing home after nursing staff had noted there to be blood in the toilet after she had been sitting on the toilet.  they did not note any urine or stool in the toilet and the patient had no acute complaints.  the patient is unfortunately a poor historian in that she has dementia and does not recall any of the events.  the patient herself has absolutely no complaints, such as abdominal pain or back pain, urinary and gi complaints.  there is no other history provided by the nursing staff from xyz.  there apparently were no clots noted within there.  she does not have a history of being on anticoagulants.,past medical history: , actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive ppd in the past.,past surgical history:  ,unknown.,social history: , no tobacco or alcohol.,medications: , listed in the medical records.,allergies:,  no known drug allergies.,physical examination: , vital signs:  stable.,general:  this is a well-nourished, well-developed female who is alert, oriented in all spheres, pleasant, cooperative, resting comfortably, appearing otherwise healthy and well in no acute distress.,heent:  visually normal.  pupils are reactive.  tms, canals, nasal mucosa, and oropharynx are intact.,neck:  no lymphadenopathy or jvd.,heart:  regular rate and rhythm.  s1, s2.  no murmurs, gallops, or rubs.,lungs:  clear to auscultation.  no wheeze, rales, or rhonchi.,abdomen:  benign, flat, soft, nontender, and nondistended.  bowel sounds active.  no organomegaly or mass noted.,gu/rectal:  external rectum was normal.  no obvious blood internally.  there is no stool noted within the vault.  there is no gross amount of blood noted within the vault.  guaiac was done and was trace positive.  visual examination anteriorly during the rectal examination noted no blood within the vaginal region.,extremities:  no significant abnormalities.,workup: , ct abdomen and pelvis was negative.  cbc was entirely within normal limits without any signs of anemia with an h and h of 14 and 42%.  cmp also within normal limits.  ptt, pt, and inr were normal.  attempts at getting the patient to give a urine were unsuccessful and the patient was very noncompliant, would not allow us to do any kind of foley catheterization.,er course:,  uneventful.  i have discussed the patient in full with dr. x who agrees that she does not require any further workup or evaluation as an inpatient.  we have decided to send the patient back to xyz with observation by the staff there.  she will have a cbc done daily for the next 3 days with results to dr. x.  they are to call him if there is any recurrences of blood or worsening of symptoms and they are to do a urinalysis at xyz for blood.,assessment: , questionable gastrointestinal bleeding at this time, stable without any obvious signs otherwise of significant bleed.",4
"reason for consultation: , abnormal ekg and rapid heart rate.,history of present illness: , the patient is an 86-year-old female.  from the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  the patient relates to have some low-grade fever.  the patient came to the emergency room.  initially showed atrial fibrillation with rapid ventricular response.  it appears that the patient has chronic atrial fibrillation.  as per the medications, they are not very clear.  husband has gone out to brief her medications.  she denies any specific chest pain.  her main complaint is shortness of breath and symptoms as above.,coronary risk factors: , no hypertension or diabetes mellitus.  nonsmoker.  cholesterol status is normal.  questionable history of coronary artery disease.  family history noncontributory.,family history:,  nonsignificant.,past surgical history: , questionable coronary artery bypass surgery versus valve replacement.,medications: , unclear at this time, but she does take coumadin.,allergies: , aspirin.,personal history: , she is married, nonsmoker.  does not consume alcohol.  no history of recreational drug use.,past medical history: , symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,review of systems,constitutional:  weakness, fatigue, and tiredness.,heent:  no history of cataract, history of blurry vision and hearing impairment.,cardiovascular:  irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,respiratory:  shortness of breath, questionable pneumonia.  no valley fever.,gastrointestinal:  no nausea, no vomiting, hematemesis or melena.,urological:  no frequency or urgency.,musculoskeletal:  arthritis, muscle weakness.,cns:  no tia.  no cva.  no seizure disorder.,skin:  nonsignificant.,psychologic:  anxiety and depression.,allergies:  nonsignificant except as mentioned above for medications.,physical examination,vital signs:  pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,heent and neck:  neck is supple.  atraumatic and normocephalic.  neck veins are flat.  no thyromegaly.,lungs:  air entry bilaterally fair.  decreased breath sounds especially in the right basilar areas.  few crackles.,heart:  normal s1 and s2, irregular.,abdomen:  soft and nontender.,extremities:  no edema.  pulse is palpable.  no clubbing or cyanosis.,cns:  grossly intact.,musculoskeletal:  arthritic changes.,psychological:  none significant.,diagnostic data: , ekg, atrial fibrillation with rapid ventricular response, and nonspecific st-t changes.  inr of 4.5, h and h 10 and 30.  bun and creatinine are within normal limits.  chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,impression:,1.  the patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  symptoms as above.,recommendations:,1.  we will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  once, if she is stable, we will consider further cardiac workup.,2.  we will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.",4
"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.",13
"she has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  she has also had bilateral carpal tunnel release.,on examination, normal range of movement of c-spine.  she has full strength in upper and lower extremities.  normal straight leg raising.  reflexes are 2 and symmetric throughout.  no babinski.  she has numbness to light touch in her right big toe.,nerve conduction studies:  the right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  bilateral tibial motor nerves could not be obtained (technical).  the remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, f-waves, and h. reflexes.,needle emg:  needle emg was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left fdi.  it revealed 2+ spontaneous activity in the right apb and fdi and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  there was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,impression:  this electrical study is abnormal.  it reveals the following:,1.  an active right c8/t1 radiculopathy.  electrical abnormalities are moderate.,2.  an active right c6/c7 radiculopathy.  electrical abnormalities are mild.,3.  evidence of chronic left c8/t1 denervation.  no active denervation.,4.  mild right lumbosacral radiculopathies.  this could not be further localized because of normal emg testing in the lower extremity muscles.,5.  there is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,results were discussed with the patient.  it appears that she has failed conservative therapy and i have recommended to her that she return to dr. x for his assessment for possible surgery to her c-spine.  she will continue with conservative therapy for the mild lumbosacral radiculopathies.",28
"preoperative diagnoses:,1.  recurrent spinal stenosis at l3-l4, l4-l5, and l5-s1.,2.  spondylolisthesis, which is unstable at l4-l5.,3.  recurrent herniated nucleus pulposus at l4-l5 bilaterally.,postoperative diagnoses:,1.  recurrent spinal stenosis at l3-l4, l4-l5, and l5-s1.,2.  spondylolisthesis, which is unstable at l4-l5.,3.  recurrent herniated nucleus pulposus at l4-l5 bilaterally.,procedure performed:,1.  microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of l3-l4, l4-l5, and l5-s1.,2.  posterior spinal fusion at the level of l4-l5 and l5-s1 utilizing local bone graft, allograft and segmental instrumentation.,3.  posterior lumbar interbody arthrodesis utilizing cage instrumentation at l4-l5 with local bone graft and allograft.  all procedures were performed under ssep, emg, and neurophysiologic monitoring.,anesthesia: , general via endotracheal tube.,estimated blood loss:  ,approximately 1000 cc.,cell saver returned:  ,approximately 550 cc.,specimens: , none.,complications: , none.,drain: , 8-inch hemovac.,surgical indications: , the patient is a 59-year-old male who had severe disabling low back pain.  he had previous lumbar laminectomy at l4-l5.  he was noted to have an isthmic spondylolisthesis.,previous lumbar laminectomy exacerbated this condition and made it further unstable.  he is suffering from neurogenic claudication.  he was unresponsive to extensive conservative treatment.  he has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,operative technique: , the patient was taken to or #5 where he was given general anesthetic by the department of anesthesia.  he was subsequently placed prone on the jackson's spinal table with all bony prominences well padded.  his lumbar spine was then sterilely prepped and draped in the usual fashion.  a previous midline incision was extended from approximate level of l3 to s1.  this was in the midline.  skin and subcutaneous tissue were debrided sharply.  electrocautery provided hemostasis.  ,electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  the lumbar fascia was identified and split in the midline.  subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of l3-s1.  once this was exposed, the transverse processes, a kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of l3-l4.  once this was completed, a self-retaining retractor was then placed.  with palpation of the spinous processes, the l4 posterior elements were noted to be significantly loosened and unstable.  these were readily mobile with digital palpation.  a rongeur was then utilized to resect the spinous processes from the inferior half of l3 to the superior half of s1.  this bone was morcellized and placed on the back table for utilization for bone grafting.  the rongeur was also utilized to thin the laminas from the inferior half of l3 to superior half of s1.  once this was undertaken, the unstable posterior elements of l4 were meticulously dissected free until wide decompression was obtained.  additional decompression was extended from the level of the inferior half of l3 to the superior half of s1.  the microscope was utilized during this portion of procedure for visualization.  there was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the l4 and l5 nerve roots crossing the disc space at l4-l5.  once this was identified, foraminotomies were created to allow additional mobility.  the wound was then copiously irrigated with antibiotic solution and suctioned dry.  working type screws, provisional titanium screws were then placed at l4-l5.  this was to allow distraction and reduction of the spondylolisthesis.  these were placed in the pedicles of l4 and l5 under direct intensification.  the position of the screws were visualized, both ap and lateral images.  they were deemed satisfactory.,once this was completed, a provisional plate was applied to the screws and distraction applied across l4-l5.  this allowed for additional decompression of the l5 and l4 nerve roots.  once this was completed, the l5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  utilizing a series of interbody spacers, a size 8 mm spacer was placed within the l4-l5 interval.  this was taken in sequence up to a 13 mm space.  this was then reduced to a 11 mm as it was much more anatomic in nature.  once this was completed, the spacers were then placed on the left side and distraction obtained.  once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of l4 and l5 bilaterally.  once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  a 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and allograft.  there were impacted at the interspace of l4-l5 under direct image intensification.  once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  the provisional screws and plates were removed.  this allowed for additional compression along l4-l5 with the cage instrumentation.  permanent screws were then placed at l4, l5, and s1 bilaterally.  this was performed under direct image intensification.  the position was verified in both ap and lateral images.  once this was completed, the posterolateral gutters were decorticated with an am2 midas rex burr down to bleeding subchondral bone.  the wound was then copiously irrigated with antibiotic solution and suction dried.  the morcellized allograft and local bone graft were mixed and packed copiously from the transverse processes of l4-s1 bilaterally.  a 0.25 inch titanium rod was contoured of appropriate length to span from l4-s1.  appropriate cross connecters were applied and the construct was placed over the pedicle screws.  they were tightened and sequenced to allow additional posterior reduction of the l4 vertebra.  once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  all connections were tightened and retightened in torque 2 specifications.  the wound was then copiously irrigated with antibiotic solution and suction dried.  the dura was inspected and noted to be free of tension.  at the conclusion of the procedure, there was noted to be no changes on the ssep, emg, and neurophysiologic monitors.  an 8-inch hemovac drain was placed exiting the wound.  the lumbar fascia was then approximated with #1 vicryl in interrupted fashion, the subcutaneous tissue with #2-0 vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  the remainder of the hemovac was assembled.  bulky compression dressing utilizing adaptic, 4x4, and abds was then affixed to the lumbar spine with microfoam tape.  he was turned and taken to the recovery room in apparent satisfactory condition.  expected surgical prognosis remains guarded.",25
"preoperative diagnosis:,  bilateral ear laceration deformities.,postoperative diagnosis:,  bilateral ear laceration deformities.,procedure:,1.  repair of left ear laceration deformity y-v plasty 2 cm.,2.  repair of right ear laceration deformity, complex repair 2 cm.,anesthesia: , 1% xylocaine, 1:100,000 epinephrine local.,brief clinical note: , this patient was brought to the operating room today for the above procedure.,operative note: , the patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  the left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  the marsupialized epithelialized tracts were pared to raw tissue.  they were pared in a fashion to create a y-v plasty with de-epithelialization of the distal v and overlap of the undermined from the proximal cephalad edge.  the 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the y-v plasty fashion to decrease the risk of notching.  bacitracin, band-aid was placed.  next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  this was not taken through the edge of the lobe to decrease the risk of notch deformity.  the laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  the 5-0 chromic sutures were used in interrupted fashion for this.  the patient tolerated the procedure well.  band-aid and bacitracin were placed.  she left the operating room in stable condition.",10
"exam:,mri left foot,clinical:, a 49-year-old female with ankle pain times one month, without a specific injury. patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,findings:,received for second opinion interpretations is an mri examination performed on 05/27/2005.,there is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,there is edema of the subcutis adipose space posterior to the achilles tendon. findings suggest altered biomechanics with crural fascial strains.,there is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. there is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. the study has been performed with the foot in neutral position. confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,there is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,normal peroneal tendons.,there is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. normal extensor hallucis longus and extensor digitorum tendons.,normal achilles tendon. there is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the achilles tendon.,normal distal tibiofibular syndesmotic ligamentous complex.,normal lateral, subtalar and deltoid ligamentous complexes.,there are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,normal plantar fascia. there is no plantar calcaneal spur.,there is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,the metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,impression:,tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,normal plantar fascia and no plantar fasciitis.,venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.",31
"chief complaint:,  joints are hurting all over and checkup.,history of present illness:,  a 77-year-old white female who is having more problems with joint pain.  it seems to be all over decreasing her mobility, hands and wrists.  no real swelling but maybe just a little more uncomfortable than they have been.  the daypro generic does not seem to be helping at all.  no fever or chills.  no erythema.,she actually is doing better.  her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema.  blood sugars seem to be little better as well.,the patient also has gotten back on her zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things.  she has had no polyuria, polydipsia, or other problems.  no recent blood pressure checks.,past medical history:,  little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with dr. xyz and is doing really quite well.  she had a pulmonary embolus with that hospitalization.,past surgical history:,  she has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases.  she also has had a parathyroidectomy but still has had some borderline elevated calcium.  also, hypertension, hyperlipidemia, as well as diabetes.  she also has osteoporosis.,social history:,  the patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks.  the patient is married.  she has three grown sons, all of which are very successful in professional positions.  one son is a gastroenterologist in san diego, california.,medications:,  nifedipine-xr 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., synthroid 0.1 mg daily, miacalcin one spray in alternate nostrils daily, ogen 0.625 mg daily, daypro 600 mg t.i.d., also lortab 7.5 two or three a day, also flexeril occasionally, also other vitamin.,allergies: , she had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.,family history:,  as far as heart disease there is none in the family.  as far as cancer two cousins had breast cancer.  as far as diabetes father and grandfather had type ii diabetes.  son has type i diabetes and is struggling with that at the moment.,review of systems:,general:  no fever, chills, or night sweats.  weight stable.,heent:  no sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes.  no hearing changes or ear problems.  no swallowing problems or mouth lesions.,endocrine:  hypothyroidism but no polyuria or polydipsia.  she watches her blood sugars.  they have been doing quite well.,respiratory:  no shortness of breath, cough, sputum production, hemoptysis or breathing problems.,cardiovascular:  no chest pain or chest discomfort.  no paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks.,gi:  as mentioned, has had diarrhea though thought to be possibly due to clostridium difficile colitis that now has gotten better.  she has had some irritable bowel syndrome and bowel abnormalities for years.,gu:  no urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections.  no vaginal bleeding or discharge.,musculoskeletal:  as above.,hematological:  she has had some anemia in the past.,neurological:  no blackouts, convulsions, seizures, paralysis, strokes, or headaches.,physical examination:,vital signs:  weight is 164 pounds.  blood pressure:  140/64.  pulse:  72.  blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.,general:  a well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly.,heent:  skull is normocephalic.  tms intact and shiny with good auditory acuity to finger rub.  pupils equal, round, reactive to light and accommodation with extraocular movements intact.  fundi benign.  sclerae and conjunctivae were normal.,neck:  no thyromegaly or cervical lymphadenopathy.  carotids are 2+ and equal bilaterally and no bruits present.,lungs:  clear to auscultation and percussion with good respiratory movement.  no bronchial breath sounds, egophony, or rales are present.,heart:  regular rhythm and rate with no murmurs, gallops, rubs, or enlargement.  pmi normal position.  all pulses are 2+ and equal bilaterally.,abdomen:  obese, soft with no hepatosplenomegaly or masses.,breasts:  no predominant masses, discharge, or asymmetry.,pelvic exam:  normal external genitalia, vagina and cervix.  pap smear done.  bimanual exam shows no uterine enlargement and is anteroflexed.  no adnexal masses or tenderness.  rectal exam is normal with soft brown stool hemoccult negative.,extremities:  the patient does appear to have some doughiness of all of the mcp joints of the hands and the wrists as well.  no real erythema.  there is no real swelling of the knees.  no new pedal edema.,lymph nodes:  no cervical, axillary, or inguinal adenopathy.,neurological:  cranial nerves ii-xii are grossly intact.  deep tendon reflexes are 2+ and equal bilaterally.  cerebellar and motor function intact in all extremities.  good vibratory and positional sense in all extremities and dermatomes.  plantar reflexes are downgoing bilaterally.,laboratory:  ,cbc shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal.  urinalysis is within normal limits.  chem profile showed a bun of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, hdl 43, ldl 121, tsh is normal, hemoglobin a1c is 5.3.,assessment:,1.  arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome.  i think we need to look at this more closely.,2.  diarrhea that seems to have resolved.  whether this is related to the above is unclear.,3.  diabetes mellitus type ii, really fairly well controlled.",14
"preoperative diagnosis: , history of polyps.,postoperative diagnoses:,1.  normal colonoscopy, left colonic diverticular disease.,2.  3+ benign prostatic hypertrophy.,procedure performed: , total colonoscopy and photography.,gross findings: , this is a 74-year-old white male here for recheck colonoscopy for a history of polyps.  after signed informed consent, blood pressure monitoring, ekg monitoring, and pulse oximetry monitoring, he was brought to the endoscopic suite.  he was given 100 mg of demerol, 3 mg of versed iv push slowly.  digital examination revealed a large prostate for which he is following up with his urologist.  no nodules.  3+ bph.  anorectal canal was within normal limits.  no stricture tumor or ulcer.  the olympus cf 20l video endoscope was inserted per anus.  the anorectal canal was visualized, was normal.  the sigmoid, descending, splenic, and transverse showed scattered diverticula.  the hepatic, ascending, cecum, and ileocecal valve was visualized and was normal.  the colonoscope was removed.  the air was aspirated.  the patient was discharged with high-fiber, diverticular diet.  recheck colonoscopy three years.",13
"preoperative diagnosis:,  hammertoe deformity of the right second digit.,postoperative diagnosis: , hammertoe deformity of the right second digit.,procedure performed: , arthroplasty of the right second digit.,the patient is a 77-year-old hispanic male who presents to abcd hospital for surgical correction of a painful second digit hammertoe.  the patient has failed attempts at conservative treatment and is unable to wear shoes without pain to his second toe.  the patient presents n.p.o. since mid night last night and consented to sign in the chart.  h&p is complete.,procedure in detail:,  after an iv was instituted by the department of anesthesia in the preoperative holding area, the patient was escorted to the operating room and placed on the table in the supine position.  using webril, the distal leg and ankle was padded and a ankle pneumatic tourniquet was placed around the right ankle, but left deflated at this time.  restraining, a lap belt was then placed around the patient's abdomen while laying on the table.  after adequate anesthesia was administered by the department of anesthesia, a local digital block using 5 cc of 0.5% marcaine plain was used to provide local anesthesia.  the foot was then prepped and draped in the normal sterile orthopedic manner.  the foot was then elevated and esmarch bandage was applied, after which time the tourniquet was inflated to 250 mmhg.  the foot was then brought down to the level of the table and stockinet was cut and reflected after the esmarch bandage was removed.  a wet and dry sponge was then used to cleanse the operative site and using a skin skribe a dorsal incisional line was outlined extending from the proximal phalanx over the proximal interphalangeal joint on to the middle phalanx.,then using a fresh #15 blade, a dorsolinear incision was made, partial thickness through the skin after testing anesthesia with one to two pickup.  then using a fresh #15 blade, incision was deepened and using medial to lateral pressure, the incision was opened into the subcutaneous tissue.  care was taken to reflect the subcutaneous tissue from the underlying deep fascia to mobilize the skin.  this was performed with the combination of blunt and dull dissection.  care was taken to avoid proper digital arteries and neurovascular bundles as were identified.  attention was then directed to the proximal interphalangeal joint and after identifying the joint line, a transverse linear incision was made over the dorsal surface of the joint.  the medial and lateral sides of the joint capsule were then also incised on the superior half in order to provide increased exposure.  following this, the proximal portion of the transected extensor digitorum longus tendon was identified using an adson-brown pickup.  it was elevated with fresh #15 blade.  the tendon and capsule was reflected along with the periosteum from the underlying bone dorsally.  following this, the distal portion of the tendon was identified in a like manner.  the tendon and the capsule as well as the periosteal tissue was reflected from the dorsal surface of the bone.  the proximal interphalangeal joint was then distracted and using careful technique, #15 blade was used to deepen the incision and while maintaining close proximity to the bone and condyles, the lateral and medial collateral ligaments were freed up from the side of the proximal phalanx head.,following this, the head of the proximal phalanx was known to have adequate exposure and was freed from soft tissues.  then using a sagittal saw with a #139 blade, the head of he proximal phalanx was resected.  care was taken to avoid the deep flexor tendon.  the head of the proximal phalanx was taken with the adson-brown and using a #15 blade, the plantar periosteal tissue was freed up and the head was removed and sent to pathology.  the wound was then flushed using a sterile saline with gentamicin and the digit was noted to be in good alignment.  the digit was also noted to be in rectus alignment.  proximal portion of the tendon was shortened to allow for removal of the redundant tendon after correction of the deformity.  then using a #3-0 vicryl suture, three simple interrupted sutures were placed for closure of the tendon and capsular tissue.  then following this, #4-0 nylon was used in a combination of horizontal mattress and simple interrupted sutures to close the skin.  the toe was noted to be in good alignment and then 1 cc of dexamethasone phosphate was injected into the incision site.  following this, the incision was dressed using a sterile owen silk soaked in saline and gentamicin.  the toe was bandaged using 4 x 4s, kling, and coban.  the tourniquet was deflated and immediate hyperemia was noted to the digits i through v of the right foot.,the patient was then transferred to the cart and was escorted to the postanesthesia care unit where the patient was given postoperative surgical shoe.  total tourniquet time for the case was 30 minutes.  while in the recovery, the patient was given postoperative instructions to include, ice and elevation to his right foot.  the patient was given pain medications of tylenol #3, quantity 30 to be taken one to two tablets every six to eight hours as necessary for moderate to severe pain.  the patient was also given prescription for cane to aid in ambulation.  the patient will followup with dr. x on tuesday in his office for postoperative care.  the patient was instructed to keep the dressings clean, dry, and intact and to not remove them before his initial office visit.  the patient tolerated the procedure well and the anesthesia with no complications.",29
"findings:,high resolution computerized tomography was performed from t12-l1 to the s1 level with reformatted images in the sagittal and coronal planes and 3d reconstructions performed. comparison: previous mri examination 10/13/2004.,there is minimal curvature of the lumbar spine convex to the left.,t12-l1, l1-2, l2-3: there is normal disc height with no posterior annular disc bulging or protrusion. normal central canal, intervertebral neural foramina and facet joints.,l3-4: there is normal disc height and non-compressive circumferential annular disc bulging eccentrically greater to the left. normal central canal and facet joints (image #255).,l4-5: there is normal disc height, circumferential annular disc bulging, left l5 hemilaminectomy and posterior central/right paramedian broad-based disc protrusion measuring 4mm (ap) contouring the rightward aspect of the thecal sac. orthopedic hardware is noted posteriorly at the l5 level. normal central canal, facet joints and intervertebral neural foramina (image #58).,l5-s1: there is minimal decreased disc height, postsurgical change with intervertebral disc spacer, posterior lateral orthopedic hardware with bilateral pedicle screws in good postsurgical position. the orthopedic hardware creates mild streak artifact which mildly degrades images. there is a laminectomy defect, spondylolisthesis with 3.5mm of anterolisthesis of l5, posterior annular disc bulging greatest in the left foraminal region lying adjacent to the exiting left l5 nerve root. there is fusion of the facet joints, normal central canal and right neural foramen (image #69-70, 135).,there is no bony destructive change noted.,there is no perivertebral soft tissue abnormality.,there is minimal to mild arteriosclerotic vascular calcifications noted in the abdominal aorta and right proximal common iliac artery.,impression:,minimal curvature of the lumbar spine convex to the left.,l3-4 posterior non-compressive annular disc bulging eccentrically greater to the left.,l4-5 circumferential annular disc bulging, non-compressive central/right paramedian disc protrusion, left l5 laminectomy.,l5-s1 postsurgical change with posterolateral orthopedic fusion hardware in good postsurgical position, intervertebral disc spacer, spondylolisthesis, laminectomy defect, posterior annular disc bulging greatest in the left foraminal region adjacent to the exiting left l5 nerve root with questionable neural impingement.,minimal to mild arteriosclerotic vascular calcifications.",20
"preoperative diagnoses: ,1.  chronic eustachian tube dysfunction.,2.  retained right pressure equalization tube.,3.  retracted left tympanic membrane.,4.  dizziness.,postoperative diagnoses:,1.  chronic eustachian tube dysfunction.,2.  retained right pressure equalization tube.,3.  retracted left tympanic membrane.,4.  dizziness.,procedure:,1.  removal of the old right pressure equalizing tube with placement of a tube.  tube used was santa barbara.,2.  myringotomy with placement of a left pressure equalizing tube.  the tube used was santa barbara.,anesthesia:,  general.,indication: , this is a 98-year-old female whom i have known for several years.  she has a marginal hearing.  with the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  so, we have kept sets of tubes in her ears at all times.  the major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,the patient was seen in the or and tubes were placed.  there were no significant findings.,procedure in detail: , after obtaining informed consent from the patient, she was brought to the neurosensory or, placed under general anesthesia.  mask airway was used.  iv had already been started.,on the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  in the same area, a small santa barbara tube was placed.  this t-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  three drops of ciprofloxacin eyedrops was placed in the ear canal.,on the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  anterior, inferior incision was made.  tympanic membrane bounced back to neutral position.  a santa barbara tube was cut to the 80% of the original length and placed in the hole.  ciprofloxacin drops were placed in the ear.  procedure completed.,estimated blood loss: , none.,complication: , none.,specimen:,  none.,disposition:,  to pacu in a stable condition.",36
"history: , the patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  he also has vacterl association with hydrocephalus.  as an infant, he underwent placement of a right modified central shunt.  on 05/26/1999, he underwent placement of a bidirectional glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, pda ligation, and placement of a 4 mm left-sided central shunt.  on 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  a repeat catheterization on 09/25/2001 demonstrated elevated glenn pressures and significant collateral vessels for which he underwent embolization.  he then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  blood pressures were found to be 13 mmhg with the pulmonary vascular resistance of 2.6-3.1 wood units.  on 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  a repeat catheterization on 09/07/2006, demonstrated mildly elevated fontan pressures in the context of a widely patent fontan fenestration and intolerance of fontan fenestration occlusion.  the patient then followed conservatively since that time.  the patient is undergoing a repeat evaluation to assess his candidacy for a fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,procedure:,  after sedation and local xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  cardiac catheterization was performed as outlined in the attached continuation sheets.  vascular entry was by percutaneous technique, and the patient was heparinized.  monitoring during the procedure included continuous surface ecg, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,using a 7-french sheath, a 6-french wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  this catheter was then exchanged for a 5-french vs catheter of a distal wire.  apposition of the right pulmonary artery over, which the wedge catheter was advanced.  the wedge catheter could then be easily advanced across the fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,using a 5-french sheath, a 5-french pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  the catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  left ventricular pressure was found to be suprasystemic.  a balloon valvoplasty was performed using a ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-french flexor sheath positioned within the right atrium.  there was a disappearance of a mild waist prior to spontaneous tear of the balloon.  the balloon catheter was then removed in its entirety.,echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  a final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  further attempts to cross tricuspid valve were thus abandoned.  attention was then directed to a fontan fenestration.  a balloon occlusion then demonstrated minimal increase in fontan pressures from 12 mmhg to 15 mmhg.  with less than 10% fall in calculated cardiac index.  the angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  a 7-french flexor sheath was again advanced cross the fenestration.  a 10-mm amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  once the stable device configuration was confirmed, device was released from the delivery catheter.  hemodynamic assessment and the angiograms were then repeated.,flows were calculated by the fick technique using an assumed oxygen consumption and contents derived from radiometer hemoximeter saturations and hemoglobin capacity.,angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,after angiography, two normal-appearing renal collecting systems were visualized.  the catheters and sheaths were removed and topical pressure applied for hemostasis.  the patient was returned to the recovery room in satisfactory condition.  there were no complications.,discussion: , oxygen consumption was assumed to be normal.  mixed venous saturation was low due to systemic arterial desaturation.  there was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  the right pulmonary veins were fully saturated.  left pulmonary veins were not entered.  there was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the fontan fenestration.  mean fontan pressures were 12 mmhg with a 1 mmhg fall in mean pressure into the distal left pulmonary artery.  right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an a-wave similar to the normal left ventricular end-diastolic pressure of 11 mmhg.  left ventricular systolic pressure was normal with at most 5 mmhg systolic gradient pressure pull-back to the ascending aorta.  phasic ascending and descending aortic pressures were similar and normal.  the calculated systemic flow was normal.  pulmonary flow was reduced to the qt-qs ratio of 0.7621.  pulmonary vascular resistance was normal at 1 wood units.,angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  the left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  there was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  angiogram with injection in the superior vena cava showed patent right bidirectional glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the glenn anastomosis and the fontan anastomosis.  there was symmetric contrast flow to both pulmonary arteries.  a large degree of contrast flowed retrograde into the fontan and shunting into the right atrium across the fenestration.  there is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  the branch pulmonaries appeared mildly hypoplastic.  levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  angiogram with injection in the fontan showed a widely patent anastomosis with the inferior vena cava.  majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,following the device occlusion of fontan fenestration, the fontan and mean pressure increased to 15 mmhg with a 3 mmhg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  there was an increase in the systemic arterial pressures.  mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  the calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a qt-qs ratio of 0.921.  angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the fontan with no protrusion into the fontan and no residual shunt and no obstruction to a fontan flow.  an ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  a small degree of contrast returned to the heart.,initial diagnoses:  ,1.  pulmonary atresia.,2.  vacterl association.,3.  persistent sinusoidal right ventricle to the coronary communications.,4.  hydrocephalus.,prior surgeries and interventions:  ,1.  systemic to pulmonary shunts.,2.  right bidirectional glenn shunt.,3.  revision of the central shunt.,4.  ligation and division of patent ductus arteriosus.,5.  occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  extracardiac fontan with the fenestration.,current diagnoses:  ,1.  favorable fontan hemodynamics.,2.  hypertensive right ventricle.,3.  aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  patent fontan fenestration.,current intervention:  ,1.  balloon dilation tricuspid valve attempted and failed.,2.  occlusion of a fontan fenestration.,management:  ,he will be discussed at combined cardiology/cardiothoracic surgery case conference.  a careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  further cardiologic care will be directed by dr. x.",36
"preoperative diagnosis:,  perirectal abscess.,postoperative diagnosis:,  perirectal abscess.,procedure: , incision and drainage (i&d) of perirectal abscess.,description of procedure: , the patient was taken to the operating room after obtaining an informed consent.  a spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,prior to prepping, i performed a digital rectal examination that showed no pathology and then i proceeded to insert an anoscope.  i found some small internal hemorrhoids and no fistulous tracts.,then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained.  all necrotic tissue was debrided.  the cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area.  the cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,estimated blood loss was minimal.  the patient tolerated the procedure well and was sent for recovery in satisfactory condition.",36
"preoperative diagnoses: , bladder laceration.,postoperative diagnoses:,  bladder laceration.,name of operation: , closure of bladder laceration.,findings:,  the patient was undergoing a cesarean section for twins.  during the course of the procedure, a bladder laceration was notices and urology was consulted.  findings were a laceration on the dome of the bladder.,procedure: , initially there as a mucosal layer of suture already placed.  this was done with 3-0 chromic catgut.  the bladder was distended and, while the bladder was distended with physiologic saline, a second layer of 3-0 chromic catgut created a watertight closure.  the second layer included the mucosa an dinner layer of the detrusor muscle.  a third layer of 2-0 dexon was used.  each of these were placed in a continuous running-locked suture technique.  there was complete watertight closure of the bladder.  hemostasis was assured and a jackson-pratt drain was brought out through a separate stab wound.  the remaining portion of the operation, both the cesarean section and the wound closure, will be dictated by dr. redmond.",37
"preoperative diagnoses:,1.  feeding disorder.,2.  down syndrome.,3.  congenital heart disease.,postoperative diagnoses:,1.  feeding disorder.,2.  down syndrome.,3.  congenital heart disease.,operation performed: , gastrostomy.,anesthesia: , general.,indications:  ,this 6-week-old female infant had been transferred to children's hospital because of down syndrome and congenital heart disease.  she has not been able to feed well and in fact has to now be ng tube fed.  her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,operative procedure:  ,after the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  the muscle was divided and the peritoneal cavity entered.  the greater curvature of the stomach was grasped with a babcock clamp and brought into the operative field.  the site for gastrostomy was selected and a pursestring suture of #4-0 nurolon placed in the gastric wall.  a 14-french 0.8 cm mic-key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 nurolon affixing the stomach to the posterior fascia.  the anterior fascia was then closed with #3-0 vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular monocryl.  the balloon was inflated to the full 5 ml.  a sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,",36
"preoperative diagnosis:,  prostate cancer, gleason score 4+3 with 85% burden and 8/12 cores positive.,postoperative diagnosis:,  prostate cancer, gleason score 4+3 with 85% burden and 8/12 cores positive.,procedure done: , open radical retropubic prostatectomy with bilateral lymph node dissection.,indications:,  this is a 66-year-old gentleman who had an elevated psa of 5.  his previous psas were in the 1 range.  trus biopsy revealed 4+3 gleason score prostate cancer with a large tumor burden.  after extensive counseling, the patient elected for retropubic radical prostatectomy.  given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  the patient consented and agreed to proceed forward.,description of procedure: , the patient was brought to the operating room here.  time out was taken to properly identify the patient and procedure going to be done.  general anesthesia was induced.  the patient was placed in the supine position.  the bed was flexed distant to the pubic area.  the patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with hibiclens soap for three minutes.  the patient was then prepped and draped in normal sterile fashion.  foley catheter was inserted sterilely in the field.  preoperative antibiotics were given within 30 minutes of skin incision.  a 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  dissection was taken down through scarpa's fascia to the level of the anterior rectus sheath.  the rectus sheath was then incised and the muscle was split in the middle.  space of rectus sheath was then entered.  the bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  the lymph node packet on the left side was then dissected.  this was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  the proximal extent of dissection was the left hypogastric artery to the level of the node of cloquet distally.  care was taken to avoid injury to the nerves.  an accessory obturator vein was noted and was ligated.  the same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  the bladder subsequently was retracted cephalad.  the prostate was then defatted up to the level of the endopelvic fascia.  the endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  a babcock was then applied around the dorsal venous complex over the urethra and the k-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  a 0-vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  using a knife on a long handle, the dorsal venous complex was then incised using the k-wire as a guide.  following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the foley catheter.  the 3-0 monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  the lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  the catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  the urethra was subsequently divided in its entirety.  a foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  the prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  throughout the case, the bleeding was controlled with the aid of a clips, vicryl sutures, silk sutures, and ties, direct pressure packing, and floseal.  following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and denonvilliers' fascia.  the seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  care was taken throughout the posterior dissection to preserve the integrity of the ureters.  the anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  following the dissection, the 5-french feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  the bladder neck was then repaired using vicryl in a tennis racquet fashion.  the rest of the mucosa was then everted.  the ureteral orifices and ureters were protected throughout the procedure.  at this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  hemostasis was then adequately obtained.  floseal was applied to the pelvis.  the bladder was then irrigated.  it was draining pink urine.  the wound was copiously irrigated.  the fascia was then closed using a #1 looped pds.  the skin wound was then irrigated, and the skin was closed with a 4-0 monocryl in subcuticular fashion.  at this point, the procedure was terminated with no complications.  the patient was then extubated in the operating room and taken in stable condition to the pacu.  please note that during the case about 3600 ml of blood was noted.  this was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.",37
"title of operation:,  mediastinal exploration and delayed primary chest closure.,indication for surgery:,  the patient is a 12-day-old infant who has undergone a modified stage i norwood procedure with a sano modification.  the patient experienced an unexplained cardiac arrest at the completion of the procedure, which required institution of extracorporeal membrane oxygenation for more than two hours following discontinuation of cardiopulmonary bypass.  the patient has been successfully resuscitated with extracorporeal membrane oxygenation and was decannulated 48 hours ago.  she did not meet the criteria for delayed primary chest closure.,preop diagnosis: , open chest status post modified stage i norwood procedure.,postop diagnosis: , open chest status post modified stage i norwood procedure.,anesthesia:,  general endotracheal.,complications:,  none.,findings: , no evidence of intramediastinal purulence or hematoma.  at completion of the procedure no major changes in hemodynamic performance.,details of the procedure: , after obtaining informed consent, the patient was brought to the room, placed on the operating room table in supine position.  following the administration of general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion and all the chest drains were removed.  the chest was then prepped and draped in the usual sterile fashion and previously placed segmental alloderm was removed.  the mediastinum was then thoroughly irrigated with diluted antibiotic irrigation and both pleural cavities suctioned.  through a separate incision and another 15-french blake drain was inserted and small titanium clips were utilized to mark the rightward aspect of the rv-pa connection as well as inferior most aspect of the ventriculotomy.  the pleural spaces were opened widely and the sternum was then spilled with vancomycin paste and closed the sternum with steel wires.  the subcutaneous tissue and skin were closed in layers.  there was no evidence of significant increase in central venous pressure or desaturation.  the patient tolerated the procedure well.  sponge and needle counts were correct times 2 at the end of the procedure.  the patient was transferred to the pediatric intensive care unit shortly thereafter in critical but stable condition.,i was the surgical attending present in the operating room in charge of the surgical  procedure throughout the entire length of the case.",2
"reason for neurological consultation: , cervical spondylosis and kyphotic deformity.  the patient was seen in conjunction with medical resident dr. x. i personally obtained the history, performed examination, and generated the impression and plan.,history of present illness: ,the patient is a 45-year-old african-american female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain.  this has subsequently resolved.  she started vigorous workouts in november 2005.  in march of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician.  by her report, she had a nerve conduction study and a diagnosis of radiculopathy was made.  she had an mri of lumbosacral spine, which was within normal limits.  she then developed a tingling sensation in the right middle toe.  symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe.  she then started getting sensory sensations in the left hand and arm.  she states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg.  symptoms have been mildly progressive.  she is unaware of any trigger other than the vigorous workouts as mentioned above.  she has no associated bowel or bladder symptoms.  no particular position relieves her symptoms.,workup has included two mris of the c-spine, which were personally reviewed and are discussed below.  she saw you for consultation and the possibility of surgical decompression was raised.  at this time, she is somewhat reluctant to go through any surgical procedure.,past medical history:,1.  ocular migraines.,2.  myomectomy.,3.  infertility.,4.  hyperglycemia.,5.  asthma.,6.  hypercholesterolemia.,medications: , lipitor, pulmicort, allegra, xopenex, patanol, duac topical gel, loprox cream, and rhinocort.,allergies: , penicillin and aspirin.,family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet.  of note, she does not drink or smoke.  she is married with two adopted children.  she is a paralegal specialist.  she used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,review of systems: , she does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,physical examination: , on examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds.  pain scale is 0.  a full general and neurological examination was personally performed and is documented on the chart.  of note, she has a normal general examination.  neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk.  she has mild postural tremor in both arms.  she has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities.  motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis.  she has hyperreflexia in her lower extremities, worse on the left.  babinski's are downgoing.,pertinent data:  ,mri of the brain from 05/02/06 and mri of the c-spine from 05/02/06 and 07/25/06 were personally reviewed.  mri of the brain is broadly within normal limits.  mri of the c-spine reveals large central disc herniation at c6-c7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema.  there is also a fairly large disc at c3-c4 with cord deformity and partial effacement of the subarachnoid space.  i do not appreciate any cord edema at this level.,impression and plan:  ,the patient is a 45-year-old female with cervical spondylosis with a large c6-c7 herniated disc with mild cord compression and signal change at that level.  she has a small disc at c3-c4 with less severe and only subtle cord compression.  history and examination are consistent with signs of a myelopathy.,results were discussed with the patient and her mother.  i am concerned about progressive symptoms.  although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis.  if she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis.  i strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation.  i agree with the previous physicians who have told her not to exercise as i am sure that her vigorous workouts and weight training since november 2005 have contributed to this problem.  i have recommended that she wear a hard collar while driving.  the results of my consultation were discussed with you telephonically.",4
"chief complaint: , cough and abdominal pain for two days.,history of present illness: , this is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days.  the patient stated that the abdominal pain was only associated with coughing.  the patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,past medical history:  ,significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,past surgical history:  ,the patient had bilateral cataract extractions in 2007, appendectomy as a child, and three d&cs in the past secondary to miscarriages.,medications: , on presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily.  the patient also takes multivitamin and lutein over-the-counter for macular degeneration.,allergies: , the patient has no known drug allergies.,family history:,  mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,social history:,  the patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years.  denies any alcohol use.  denies any iv drug use.,physical examination:  ,general:  this is a 76-year-old female, well nourished.  vital signs:  on presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20.  heent:  anicteric sclerae.  conjunctivae pink.  throat was clear.  mucosal membranes were dry.  chest:  coarse breath sounds bilaterally at the bases.  cardiac:  s1 and s2.  no murmurs, rubs or gallops.  no evidence of carotid bruits.  abdomen:  positive bowel sounds, presence of soreness on examination in the abdomen on palpation.  there is no rebound or guarding.  extremities:  no clubbing, cyanosis or edema.,hospital course: , the patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes.  there is no evidence of effusion or consolidation.  degenerative changes were seen in the shoulder.  the patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern.  urinalysis showed no evidence of infection as well as her influenza a&b were negative.  preliminary blood cultures have been with no growth to date status post 48 hours.  the patient was started on cefepime 1 g iv q.12h. and given iv hydration.  she has also been on xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol.  in terms of prophylactic measures, she received lovenox subcutaneously for dvt prophylaxis.  currently today, she feels much improved with still only a mild cough.  the patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18.  her white count on presentation was 13.6 and yesterday's white count was 10.3.,final diagnosis:,  bronchitis.,disposition: , the patient will be going home.,medications: , hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily.  also, avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,diet:,  to follow a low-salt diet.,activity:,  as tolerated.,followup:  ,to follow up with dr. abc in two weeks.",4
"general evaluation: ,(twin a),fetal cardiac activity: normal at 166 bpm,fetal lie: twin a lies to the maternal left.,fetal presentation: cephalic,placenta: posterior fused placenta grade i-ii,uterus: normal,cervix: closed,adnexa: not seen,amniotic fluid: there is a single 3.9cm anterior pocket.,biometry:,bpd: 8.7cm consistent with 35 weeks, 1 day,hc: 30.3cm consistent with 33 weeks, 5 days.,ac: 28.2cm consistent with 32 weeks, 1 day,fl:",22
"preoperative diagnosis: , a 39-week intrauterine pregnancy with complete breech presentation.,postoperative diagnosis:,  a 39-week intrauterine pregnancy in vertex presentation, status post successful external cephalic version.,procedure: , external cephalic version.,complications:,  none.,procedure in detail:  ,the patient was brought to labor and delivery where a reactive fetal heart tracing was obtained.  the patient was noted to have irregular contractions.  she was given 1 dose of subcutaneous terbutaline which resolved her contraction.  a bedside ultrasound was performed which revealed single intrauterine pregnancy and complete breech presentation.  there was noted to be adequate fluid.  using manual pressure, the breech was manipulated in a forward roll fashion until a vertex presentation was obtained.  fetal heart tones were checked intermittently during the procedure and were noted to be reassuring.  following successful external cephalic version, the patient was placed on continuous external fetal monitoring.  she was noted to have a reassuring and reactive tracing for 1 hour following the external cephalic version.  she did not have regular contractions and therefore she was felt to be stable for discharge to home.  she was given appropriate labor instructions.",36
"preoperative diagnosis: , shunt malfunction.  the patient with a ventriculoatrial shunt.,postoperative diagnosis:,  shunt malfunction.  the patient with a ventriculoatrial shunt.,anesthesia: , general endotracheal tube anesthesia.,indications for operation: , headaches, fluid accumulating along shunt tract.,findings: , partial proximal shunt obstruction.,title of operation:,  endoscopic proximal shunt revision.,specimens: , none.,complications:,  none.,devices: , portnoy ventricular catheter.,operative procedure:,  after satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  the old right frontal scalp incision was reopened in a curvilinear manner, and the bactiseal ventricular catheter was identified as it went into the right frontal horn.  the distal end of the va shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  we could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  a portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  it flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 ethibond sutures.  the wounds were irrigated out with bacitracin and closed in a routine manner using two 3-0 vicryl for the galea and a 4-0 running monocryl for the scalp followed by mastisol and steri-strips.  the patient was awakened and extubated having tolerated the procedure well without complications.  it should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.",21
"preoperative diagnosis:,  left elbow with retained hardware.,postoperative diagnosis: , left elbow with retained hardware.,procedure: , ,1.  left elbow manipulation.,2.  hardware removal of left elbow.,anesthesia:  ,surgery was performed under general anesthesia.,complications:,  there were no intraoperative complications.,drains: , none.,specimens: , none.,intraoperative finding: , preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  we increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,local anesthetic:  ,10 ml of 0.25% marcaine.,history and physical: , the patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  the patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  the patient also sustained a nondisplaced right glenoid neck fracture.  the patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a dynasplint.  the patient is neurologically intact distally.  given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  risks and benefits of the surgery were discussed.  the risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  all questions were answered and the parents agreed to the above plan.,procedure:  ,the patient was taken to the operating room and placed supine on the operating table.  general anesthesia was then administered.  the patient's left upper extremity was then prepped and draped in a standard surgical fashion.  using fluoroscopy, the patient's k-wire was located.  an incision was made over his previous scar.  a subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  the k-wires were easily palpable.  a small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  the wound was then irrigated.  the triceps split was now closed using #2-0 vicryl.  the subcutaneous tissue was also closed using #2-0 vicryl and the skin with #4-0 monocryl.  the wound was clean and dry and dressed with steri-strips, xeroform, and 4 x 4s, as well as bias.  a total of 10 ml of 0.25% marcaine was injected into the incision, as well as the joint line.  at the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,diagnostic impression:  ,the postoperative films demonstrated no fracture, no retained hardware.  the patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,postoperative plan: , the patient will restart physical therapy and dynasplint in 3 days.  the patient is to follow up in 1 week's time for a wound check.  the patient was given tylenol no.  3 for pain.",36
"procedure performed: , endotracheal intubation.,indication for procedure:  ,the patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  pco2 was 29 and po2 was 66 on the 15 liters.,narrative of procedure: , the patient was given a total of 5 mg of versed, 20 mg of etomidate, and 10 mg of vecuronium.  he was intubated in a single attempt.  cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap a lavage with 100 ml of normal sterile saline for cytology, afb, and fungal smear and culture.  a separate trap b was then lavaged for bacterial c&s and gram stain and was sent for those purposes.  the patient tolerated the procedure well.",2
"procedure: , endoscopy.,clinical indications: , intermittent rectal bleeding with abdominal pain.,anesthesia: , fentanyl 100 mcg and 5 mg of iv versed.,procedure:,  the patient was taken to the gi lab and placed in the left lateral supine position.  continuous pulse oximetry and blood pressure monitoring were in place.  after informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  with swallowing, the scope was advanced down the esophagus into the body of the stomach.  the scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  it appeared free of stricture, neoplasm, or ulceration.  samples were obtained from the antrum and prepyloric area to check for helicobacter, rapid urease, and additional samples were sent to pathology.  retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  the scope was then slowly removed.  the distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  the remaining portion of the esophagus was normal.,impression:,  abdominal pain.  symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,recommendations:,  await results of clo testing and biopsies.  return to clinic with dr. spencer in 2 weeks for further discussion.",36
"preoperative diagnosis: , recurrent tonsillitis.,postoperative diagnosis: , recurrent tonsillitis.,procedure:  ,adenotonsillectomy.,complications:,  none.,procedure details:, the patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a mcivor mouthgag placed.  the adenoid bed was examined and was moderately hypertrophied.  adenoid curettes were used to remove this tissue and packs placed.  next, the right tonsil was grasped with a curved allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  a similar procedure was performed on the contralateral tonsil.  following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  the patient was then allowed to awaken and was brought to the recovery room in stable condition.",10
"admission diagnoses:,1.  severe menometrorrhagia unresponsive to medical therapy.,2.  severe anemia.,3.  fibroid uterus.,discharge diagnoses:,1.  severe menometrorrhagia unresponsive to medical therapy.,2.  severe anemia.,3.  fibroid uterus.,operations performed:,1.  hysteroscopy.,2.  dilatation and curettage (d&c).,3.  myomectomy.,complications: , large endometrial cavity fibroid requiring careful dissection and excision.,blood transfusions: , two units of packed red blood cells.,infection: , none.,significant lab and x-ray: , posttransfusion of the 2nd unit showed her hematocrit of 25, hemoglobin of 8.3.,hospital course and treatment: , the patient was admitted to the surgical suite and taken to the operating room where a dilatation and curettage (d&c) was performed.  hysteroscopy revealed a large endometrial cavity fibroid.  careful shaving and excision of this fibroid was performed with removal of the fibroid.  hemostasis was noted completely at the end of this procedure.  postoperatively, the patient has done well.  the patient was given a 2nd unit of packed red blood cells because of intraoperative blood loss.  the patient is now ambulating without difficulty and tolerating her diet.  the patient desires to go home.  the patient is discharged to home.,discharge condition: , stable.,discharge instructions:  ,regular diet, bedrest for 1 week with slow return to normal activities over the ensuing 2 to 3 weeks, pelvic rest for 6 weeks.  vicodin tablets 1 tablet p.o. q.4-6 h. p.r.n. pain, multiple vitamin 1 tab p.o. daily, ferrous sulfate  tablets 1 tablet p.o. daily.  ambulate with assistance at home only.  the patient is to return to see dr. x p.r.n. plus tuesday, 6/16/2009 for further followup care.  the patient was given full and complete postop and discharge instructions.  all her questions were answered.",9
"consult request for:, medical management.,the patient has been in special procedures now for over 2 hours and i am unable to examine.,history of present illness:, obtained from dr. a on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. she was unfortunately outside of the window for emergent treatment and had a negative ct scan of the head. was started on protocol medication and that is similar to tpa, which is an investigational study.,during the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. her heart rate was 130. she was brought down with cardizem. she received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as tpa has no obvious known association with this.,at that time the patient became comatose and required emergent intubation and paralyzation. her diastolic at that time rose up to 190, likely the result of the acute second stroke. she is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. dr. a has updated the family to her extremely guarded and critical prognosis.,at present, it is not known yet, we do not have the stat echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,review of systems:, complete review of systems is unobtainable at present. from what i can tell, is that she is scheduled for an upcoming bladder distension surgery and i do not know if this is why she is off coumadin for chronic afib or what, at this point. tremor for 3-4 years, diagnosed as early parkinson's.,past medical history:, gerd, hypertension times 20 years, arthritis, parkinson's, tia, chronic atrial fibrillation, on coumadin three years.,past surgical history:, cholecystectomy, tah 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,allergies:, morphine, sulfas (rash), prozac.,medications at home: lanoxin 0.25 daily; inderal la 80 daily; mobic 7.5 daily; robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen prn; darvocet-n 100 prn.,social history:, she does not drink or smoke. lives in fayetteville, tennessee.,family history:, mother died of cancer, unknown type. dad died of an mi.,vaccination status: unknown.,physical examination:,vital signs: on arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,general: she was apparently alert and able to give history on arrival. currently do not have any available vital signs or physical exam, as i cannot get to the patient.,laboratory: ,reviewed and are remarkable for white count of 13 with 76 neutrophils. bmp is normal, except for a blood sugar of 157, hemoglobin a1c is pending. tsh 2.1, cholesterol 165, digoxin 1.24, cpk 57. abg 7.47/32/459 on 100%. magnesium 1.5. esr 9, coags normal.,ekg is pending my review.,chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,chest x-ray, shoulder films and ct scan of the head: i have reviewed. chest x-ray has good et tube placement. she has mild cardiomegaly. some mild interstitial opacities consistent with ogd and minimal amount of atherosclerosis of the aorta.,ct scan of the head: i do not see any active bleeding.,x-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,assessment/plan/problems:,1. large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. obviously she is in critical condition and stable with multiple strokes. one must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. we need stat records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. i have ordered a stat echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a pfo we may be able to better prognosticate at this point. obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by dr. a and interventional radiology.,2. hypertension/atrial fibrillation: this will be a difficult management and the fact that she has been on a beta-blocker for parkinson's, she may have withdrawal to the beta-blockers as we remove this. given her atrial fibrillation, i do agree the safest agent right now is to use a cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. also, would use it to control the atrial fibrillation. we would, however, be very cautious not to put her in heart block with the digoxin and the beta-blocker on board. weighing all risks and benefits, i think that given the fact that she has a beta-blocker on board and digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. if, however, we run into trouble with this, i would prefer to switch her to brevibloc or an esmolol drip and see how she does, as she may withdraw from the beta-blocker. i will be watching this closely and managing the hypertension as i see fit at the moment, based on all factors. will also ask cardiology if she has one that sees her here, to help guide this. her digoxin level is appropriate, as well as a tsh. i do not feel that we need to work this up further, other than the stat echo and ultrasound of the leg.,3. respiratory failure requiring ventilator: i have discussed this with dr. devlin, we do not feel the need to hyperventilate her at present. we will keep her comfortable on the breathing machine and try to keep her ph in a normal range, around 7.4, and her co2 in the 30 to 40 range. if she has brain swelling, we will need to hyperventilate her to a pco2 of 30 and a ph of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. optimize electrolytes as you can.,5. deep vein thrombosis prophylaxis for now, with thigh-high ted hose, possibly scds, although i do not have experience with the vampire/venom to know if we need to worry about dic which the scds may worsen. will follow daily cbcs for that.,6. nutrition: will go ahead and start a low dose of tube feeds and hope that she does survive.,i will defer all updates to the family for the next 24 to 48 hours to dr. devlin's expertise, given her unknown and fluctuating neurologic prognosis.,thank you so much for allowing us to participate in her care. we will be happy to do all medication treatment until the point that i feel that i would need any help from critical care. i believe that we will be able to manage her fully at this point, for simplicity sake.",14
"preoperative diagnoses:,1.  medial meniscal tear, posterior horn of left knee.,2.  carpal tunnel syndrome chronic right hand with intractable pain, numbness, and tingling.,3.  impingement syndrome, right shoulder with acromioclavicular arthritis, bursitis, and chronic tendonitis.,postoperative diagnoses:,1.  carpal tunnel syndrome, right hand, severe.,2.  bursitis, tendonitis, impingement, and ac arthritis, right shoulder.,3.  medial and lateral meniscal tears, posterior horn old, left knee.,procedure:,1.  right shoulder arthroscopy, subacromial decompression, distal clavicle excision, bursectomy, and coracoacromial ligament resection.,2.  right carpal tunnel release.,3.  left knee arthroscopy and partial medial and lateral meniscectomy.,anesthesia: , general with regional.,complications:  ,none.,disposition: , to recovery room in awake, alert, and in stable condition.,operative indications: , a very active 50-year-old gentleman who had the above problems and workup revealed the above problems.  he failed nonoperative management.  we discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and he gave his fully informed consent to the following procedure.,operative report in detail: , the patient was brought to the operating room and placed in the supine position on the operating room table.  after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  all bony prominences were padded.  the right shoulder was prepped and draped in the usual sterile manner using standard betadine prep, entered through three standard arthroscopic portals anterolateral and posterior incising the skin with a knife using sharp and blunt trocar.,serial examination of the intraarticular portion of the shoulder showed all the structures to be normal including the biceps tendon ligaments, articular surfaces, and labrum.  subacromial space was entered.  visualization was poor due to the hemorrhagic bursitis, and this was resected back.  it was essentially a type-3 acromion, which was converted to a type 1 by aiming the burr anterior from the posterior portal excising the larger anterior spur.  rotator cuff was little bit fray, but otherwise intact.  thus, the deep deltoid bursa and the markedly thickened coracoacromial ligament were removed.  the burr was then introduced to the anterior portal and the distal clavicle excision carried out.  the width of burr about 6 mm being careful to preserve the ligaments in the capsule, but removing the spurs and the denuded arthritic joint.,the patient tolerated the procedure very well.  the shoulder was then copiously irrigated, drained free of any residual debris.  the wound was closed with 3-0 prolene.  sterile compressive dressing applied.,the patient was then placed on his back in the supine position and the right upper extremity and the left lower extremity were prepped and draped in usual sterile manner using a standard betadine prep.,the attention was first turned to the right hand where it was elevated, exsanguinated using an esmarch bandage, and the tourniquet was inflated to 250 mmhg for about 25 minutes.  volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis.  tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors being careful to avoid the neurovascular structures.,cautery was used for hemostasis.  the never had an hourglass appearance where it was a kind of constricted as a result of the compression from the ligament, and so a small amount of celestone was dripped onto the nerve to help quite it down.  the patient tolerated this portion of the procedure very well.  the hand was then irrigated, closed with monocryl and prolene, and sterile compressive dressing was applied and the tourniquet deflated.,attention was then turned to the left knee where it was entered through inferomedial and inferolateral portals incising the skin with a knife and using sharp and blunt trocars.  after entering the knee through inferomedial and inferolateral standard arthroscopic portals, examination of the knee showed a displaced bucket-handle tear in the medial meniscus and a radial tear at the lateral meniscus.  these were resected back to the stable surface using a basket forceps and full-radius shaver.  there was no evidence of any other significant arthritis in the knee.  there was a lot of synovitis, and so after the knee was irrigated out and free of any residual debris, the knee was injected with celestone and marcaine with epinephrine.,the patient tolerated the procedure very well, and the wounds were closed with 3-0 prolene and sterile compressive dressing was applied, and then the patient was taken to the recovery room, extubated, awake, alert, and in stable condition.",36
"identifying data: , the patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,chief complaint: , ""i am not sure."" the patient has poor insight into hospitalization and need for treatment.,history of present illness: , the patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in houston, texas.  according to mental health professionals, the patient had been noncompliant with medications for approximately two weeks.  the patient had taken an airplane from houston to seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in seattle.  the patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail.  the patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,past psychiatric history: , history of schizophrenia, chronic paranoid.  the patient as noted has been treated in houston but has not had recent treatment or medications.,past medical history:  ,no acute medical problems noted.,current medications: , none.  the patient was most recently treated with invega and abilify according to his records.,family social history: , the patient resides with his father in houston.  the patient has no known history of substances abuse.  the patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,family psychiatric history:,  need to increase database.,mental status examination:,attitude:  calm and cooperative.,appearance:  shows poor hygiene and grooming.,psychomotor:  behavior is within normal limits without agitation or retardation.  no eps or tds noted.,affect:  is suspicious.,mood:  anxious but cooperative.,speech:  shows normal rate and rhythm.,thoughts:  disorganized,thought content:  remarkable for paranoia ""they want to hurt me."",psychosis:  the patient endorses paranoid delusions as above.  the patient denies auditory hallucinations.,suicidal/homicidal ideation:  the patient denies on admission.,cognitive assessment:  grossly intact.  the patient is alert and oriented x 3.,judgment:  poor, shown by noncompliance with treatment.,assets:  include stable physical status.,limitations:  include recurrent psychosis.,formulation:  ,the patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,initial impression:,axis i:  schizophrenia, chronic paranoid.,axis ii:  none.,axis iii:  none.,axis iv:  severe.,axis v:  10.,estimated length of stay: , 12 days.,plan:  ,the patient will be restarted on invega and abilify for psychosis.  the patient will also be continued on cogentin for eps.  increased database will be obtained.",30
"reason for consultation:,  newly diagnosed head and neck cancer.,history of present illness: , the patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  he was also noted to have palpable level 2 cervical lymph nodes.  his staging is t3 n2c m0 stage iv invasive squamous cell carcinoma of the head and neck.  the patient comes in to the clinic today after radiation oncology consultation.  his otolaryngologist performed a direct laryngoscopy with biopsy on july 29, 2010.  the patient reports that in december-january timeframe, he had noted some difficulty swallowing and ear pain.  he had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  his symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  he was then referred to dr. x and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  he was noted to have bilateral neck nodes.  his biopsy was positive for squamous cell carcinoma.,past medical history:,  significant for mild hypertension.  he has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,allergies: ,  penicillin.,current medications: , lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., lortab 7.5/500 mg q 4h p.r.n.,family history: , significant for father who has stroke and grandfather with lung cancer.,social history: , the patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  he is retired from the air force, currently works for lockheed martin.  he was born and raised in new york.  he does have a smoking history, about a 20 pack-year history and he reports quitting on july 27.  he does drink alcohol socially. no use of illicit drugs.,review of systems:  ,the patient's chief complaint is fatigue.  he has difficulty swallowing and dysphagia.  he is responding well to lortab and tylenol for pain control.  he denies any chest pain, shortness of breath, fevers, chills and night sweats.  the rest of his review of systems is negative.,physical exam:,vitals:",15
"procedures performed:,1. left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. left ventricular angiography was not performed.,3. right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. right femoral artery angiography.,5. perclose to seal the right femoral arteriotomy.,indications for procedure:, patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. the patient presented with what appeared to be a copd exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-st elevation myocardial infarction. he was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,description of procedure:, after informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. the patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. then, a 6-french sheath was inserted into the right femoral artery. over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-french jl4 diagnostic catheter to image the left coronary artery, a 6-french jr4 diagnostic catheter to image the right coronary artery, a 6-french angled pigtail catheter to measure left ventricular pressure. at the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. then, a perclose was used to seal the right femoral arteriotomy.,hemodynamic data:, the opening aortic pressure was 91/63. the left ventricular pressure was 94/13 with an end-diastolic pressure of 24. left ventricular ejection fraction was not assessed, as ventriculogram was not performed. the patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,coronary angiogram:, the left main coronary artery was angiographically okay. the lad had mild diffuse disease. there appeared to be distal tapering of the lad. the left circumflex had mild diffuse disease. in the very distal aspect of the circumflex after om-3 and om-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. the runoff from this area appeared to be a very small plom type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. the right coronary artery had mild diffuse disease. the plv branch was 100% occluded at its ostium at the crux. the pda at the ostium had an 80% stenosis. the pda was a fairly sizeable vessel with a long course. the right coronary is dominant.,conclusion:, mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. this circumflex appears to be chronically diseased and has areas that appear to be subtotal. there is a 100% plv branch which is also chronic and reported in his angiogram in the 1990s. there is an ostial 80% right pda lesion. the plan is to proceed with percutaneous intervention to the right pda.,the case was then progressed to percutaneous intervention of the right pda. a 6-french jr4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. the lesion was crossed with a long bmw 0.014 guidewire. then, we ballooned the lesion with a 2.5 x 9 mm maverick balloon. subsequently, we stented the lesion with a 2.5 x 16 mm taxus drug-eluting stent with a nice angiographic result. the patient tolerated the procedure very well, without complications.,angioplasty conclusion:, successful percutaneous intervention with drug-eluting stent placement to the ostium of the pda.,recommendations:, aspirin indefinitely, and plavix 75 mg p.o. daily for no less than six months. the patient will be dispositioned back to telemetry for further monitoring.,total medications during procedure:, versed 1 mg and fentanyl 25 mcg for conscious sedation. heparin 8400 units iv was given for anticoagulation. ancef 1 g iv was given for closure device prophylaxis.,contrast administered:, 200 ml.,fluoroscopy time:, 12.4 minutes.",2
"cc:, rapidly progressive amnesia.,hx: ,this 63 y/o rhm presented with a 1 year history of progressive anterograde amnesia. on presentation he could not remember anything from one minute to the next. he also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. he underwent extensive evaluation at the mayo clinic and an mri there revealed increased signal on t2 weighted images in the mesiotemporal lobes bilaterally. there was no mass affect. the areas mildly enhanced with gadolinium.,pmh:, 1) cad; mi x 2 (1978 and 1979). 2) pvd; s/p aortic endarterectomy (3/1991). 3)htn. 4)bilateral inguinal hernia repair.,fhx/shx:, mother died of a stroke at age 58. father had cad and htn. the patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. he had been a feed salesman all of his adult life.,ros:, unremarkable. no history of cancer.,exam:, bp 136/75 hr 73 rr12 t36.6,ms: alert but disoriented to person, place, time. he could not remember his birthdate, and continually asked the interviewer what year it was. he could not remember when he married, retired, or his grandchildren's names. he scored 18/30 on the follutein's mmse with severe deficits in orientation and memory. he had moderate difficulty naming. he repeated normally and had no constructional apraxia. judgement remained good.,cn: unremarkable.,motor: full strength throughout with normal muscle tone and bulk.,sensory: intact to lt/pp/prop,coordination: unremarkable.,station: no pronator drift, truncal ataxia or romberg sign.,gait: unremarkable.,reflexes: 3+ throughout with downgoing plantar responses bilaterally.,gen exam: unremarkable.,studies:, mri brain revealed hyperintense t2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. mri and ct of the chest and ct of the abdomen showed no evidence of lymphadenopathy or tumor. eeg was normal awake and asleep. antineuronal antibody screening was unremarkable. csf studies were unremarkable and included varicella zoster, herpes zoster, hiv and htlv testing, and cytology. the patient underwent stereotactic brain biopsy at the mayo clinic which showed inflammatory changes, but no organism or etiology was concluded. tft, b12, vdrl, esr, crp, ana, spep and folate studies were unremarkable. neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,impression:, limbic encephalitis secondary to cancer of unknown origin.,he was last seen 7/26/96. mmse 20/30 and category fluency 20 . disinhibited affect. mild right grasp reflex. the clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .",4
"admitting diagnosis: , encephalopathy related to normal-pressure hydrocephalus.,chief complaint:,  diminished function secondary to above.,history:  ,this pleasant gentleman was recently admitted to abcd medical center and followed by the neurosurgical staff, including dr. x, where normal-pressure hydrocephalus was diagnosed.  he had a shunt placed and was stabilized medically.  he has gotten a return of function to the legs and was started on some early therapy.  significant functional limitations have been identified and ongoing by the rehab admission team.  significant functional limitations have been ongoing.  he will need to be near-independent at home for periods of time, and he is brought in now for rehabilitation to further address functional issues, maximize skills and safety and allow a safe disposition home.,past medical history: , positive for prostate cancer, intermittent urinary incontinence and left hip replacement.,allergies: , no known drug allergies.,current medications,1.  tylenol as needed.  ,2.  peri-colace b.i.d.,social history:,  he is a nonsmoker and nondrinker.  prior boxer.  he lives in a home where he would need to be independent during the day.  family  relatives intermittently available.  goal is to return home to an independent fashion to that home setting.,functional history: , prior to admission was independent with activities of daily living and ambulatory skills.  presently, he has resumed therapies and noted to have supervision levels for most activities of daily living.  memory at minimal assist.  walking at supervision., review of systems:  ,negative for headaches, nausea, vomiting, fevers, chills, shortness of breath or chest pain currently.  he has had some dyscoordination recently and headaches on a daily basis, most days, although the tylenol does seem to control that pain.,physical examination,vital signs:  the patient is afebrile with vital signs stable.,heent:  oropharynx clear, extraocular muscles are intact.,cardiovascular:  regular rate and rhythm, without murmurs, rubs or gallops.,lungs:  clear to auscultation bilaterally.,abdomen:  nontender, nondistended,  positive bowel sounds.,extremities:  without clubbing, cyanosis, or edema.  the calves are soft and nontender bilaterally.,neurologic:  no focal, motor or sensory losses through the lower extremities.  he moves upper and lower extremities well.  bulk and tone normal in the upper and lower extremities.  cognitively showing intact with appropriate receptive and expressive skills.,impression ,",20
"1.  the left ventricular cavity size and wall thickness appear normal.  the wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%.  there is near-cavity obliteration seen.  there also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function.  there is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by doppler examination.,2.  the left atrium appears mildly dilated.,3.  the right atrium and right ventricle appear normal.,4.  the aortic root appears normal.,5.  the aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6.  there is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7.  the tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension.  estimated pulmonary artery systolic pressure is 49 mmhg.  estimated right atrial pressure of 10 mmhg.,8.  the pulmonary valve appears normal with trace pulmonary insufficiency.,9.  there is no pericardial effusion or intracardiac mass seen.,10.  there is a color doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11.  the study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,",31
"operative note:  ,the patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  the penis was inspected.  the meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  this was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  the meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  an incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  the glans was undermined with sharp dissection and hemostasis was obtained with a bovie.  using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  there was good viability of the skin.  the incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  this was removed and hemostasis was obtained with a bovie.  0.25% marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  at the conclusion of the procedure, vaseline gauze was wrapped around the penis.  there was good hemostasis and the patient was sent to the recovery room in stable condition.",37
"preoperative diagnosis: , large and invasive recurrent pituitary adenoma.,postoperative diagnosis:,  large and invasive recurrent pituitary adenoma.,operation performed: , endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,indications for procedure: , this man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  he did not return for followup or radiotherapy as instructed, and the tumor has regrown.  for this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  the high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  many risks including csf leak and blindness were discussed in detail.  after clear understanding of all the same, he elected to proceed ahead with surgery.,procedure:  ,the patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  care was taken to pad all pressure points appropriately.  the back was prepped and draped in usual sterile manner.,a 14-gauge tuohy needle was introduced into the lumbar subarachnoid space.  clear and colorless csf issued forth.  a catheter was inserted to a distance of 40 cm, and the needle was removed.  the catheter was then connected to a closed drainage system for aspiration and infusion.,this no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  this improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,the patient was then placed supine, and the 3-point headrest was affixed.  he was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  care was taken to pad all pressure points appropriately.  the fluoroscope c-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  the metallic arm was then connected to the table for the use of the endoscope.  the oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,a transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  hemostasis was obtained.  the wound was carefully closed in layers.,i then advanced a 0-degree endoscope up the left nostril.  the middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  needle bovie electrocautery was used to clear mucosa away from the ostium.  the perpendicular plate of the ethmoid had already been separated from the sphenoid.  i entered into the sphenoid.,there was a tremendous amount of dense fibrous scar tissue present, and i slowly and carefully worked through all this.  i identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which i exposed the very medial portion of.  the opening was wide until i had the horizontal portion of the floor to the tuberculum sella present.,the operating microscope was then utilized.  working under magnification, i used hypophysectomy placed in the nostril.,the dura was then carefully opened in the midline, and i immediately encountered tissue consistent with pituitary adenoma.  a frozen section was obtained, which confirmed this diagnosis without malignant features.,slowly and meticulously, i worked to remove the tumor.  i used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  the tumor was moderately vascular and very fibrotic.,slowly and carefully, i systematically entered the sellar contents until i could see the cavernous sinus wall on the left and on the right.  there appeared to be cavernous sinus invasion on the left.  it was consistent with what we saw on the mri imaging.,the portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  a large amount of this was removed.  there was a csf leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,under high magnification, i actually worked up into this cavity and performed a very radical excision of tumor.  while there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  in fact, i reinserted the endoscope and could see the optic chiasm well.,i reasoned that i had therefore achieved the goal with that is of a radical excision and decompression.  attention was therefore turned to closure.,the wound was copiously irrigated with bacitracin solution, and meticulous hemostasis was obtained.  i asked anesthesiology to perform a valsalva maneuver, and there was no evidence of bleeding.,attention was turned to closure and reconstruction.  i placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  using a polypropylene insert, i reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,duraseal was placed over this, and the sphenoid sinus was carefully packed with fat and duraseal.,i inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  the middle turbinates were then restored to their anatomic position.  there was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  sterile dressings were applied, and the operation was terminated.,the patient tolerated the procedure well and left to the recovery room in excellent condition.  the sponge and needle counts were reported as correct, and there were no intraoperative complications.,specimens were sent to pathology consisting of tumor.",20
"ct abdomen with and without contrast and ct pelvis with contrast,reason for exam: , generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,technique:,  axial ct images of the abdomen were obtained without contrast.  axial ct images of the abdomen and pelvis were then obtained utilizing 100 ml of isovue-300.,findings: , the liver is normal in size and attenuation.,the gallbladder is normal.,the spleen is normal in size and attenuation.,the adrenal glands and pancreas are unremarkable.,the kidneys are normal in size and attenuation.,no hydronephrosis is detected.  free fluid is seen within the right upper quadrant within the lower pelvis.  a markedly thickened loop of distal small bowel is seen.  this segment measures at least 10-cm long.  no definite pneumatosis is appreciated.  no free air is apparent at this time.  inflammatory changes around this loop of bowel.  mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  no complete obstruction is suspected, as there is contrast material within the colon.  postsurgical changes compatible with the partial colectomy are noted.  postsurgical changes of the anterior abdominal wall are seen.  mild thickening of the urinary bladder wall is seen.,impression:,1.  marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  an inflammatory process such as infection or ischemia must be considered.  close interval followup is necessary.,2.  thickening of the urinary bladder wall is nonspecific and may be due to under distention.  however, evaluation for cystitis is advised.",19
"preoperative diagnosis:,  chest wall mass, left.,postoperative diagnosis: , chest wall mass, left.,procedure:,  removal of chest wall mass.,description of procedure: , after obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic.  the time-out process was followed and preoperative antibiotics were given.  the patient was in the supine position and was prepped and draped in the usual fashion.,the area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.  an incision was made directly on the mass and carried down to the ribs.  this is where the several chondral cartilages of the lower ribs meet.  so i believe they were isolated in 9th rib anteriorly and i was able to encircle it.  the medial area was __________.  there was no way to perform same procedure there, so what i did, i took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs.  there was also a separate sharp growth of the mass growing superiorly.  apparently, i was able to excise the mass and actually it was much larger than it was palpated externally.  this may be due to an extension towards the inside of his chest.  hemostasis was revised.  the internal mammary was intact and there was no obvious penetration of the pleural cavity.  the specimen was sent to pathology and then we proceeded to close the defect.  obviously, the space between the ribs cannot be approximated.  so what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of monocryl.,the patient tolerated the procedure well.  estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.",36
"history of present illness:,  the patient is a 63-year-old white male who was admitted to the hospital with chf and lymphedema.  he also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of ca of the lung.  this consultation was made for better control of his blood sugars.  on questioning, the patient says that he does not have diabetes.  he says that he has never been told about diabetes except during his last admission at jefferson hospital.  apparently, he was started on glipizide at that time.  his blood sugars since then have been good and he says when he went back to jefferson three weeks later, he was told that he does not have a sugar problem.  he is not sure.  he is not following any specific diet.  he says ""my doctor wants me to lose 30-40 pounds in weight"" and he would not mind going on a diet.  he has a long history of numbness of his toes.  he denies any visual problems.,past medical history: , as above that includes ca of the lung, copd, bilateral cataracts.  he has had chronic back pain.  there is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown.,social history: , the patient has been a smoker since the age of 10.  so, he was smoking 2-3 packs per day.  since being started on chantix, he says he has cut it down to half a pack per day.  he does not abuse alcohol.,medications: ,1.  glipizide 5 mg p.o. daily.,2.  theophylline.,3.  z-pak.,4.  chantix.,5.  januvia 100 mg daily.,6.  k-lor.,7.  oxycontin.,8.  flomax.,9.  lasix.,10.  advair.,11.  avapro.,12.  albuterol sulfate.,13.  vitamin b tablet.,14.  oxycontin and oxycodone for pain.,family history: , positive for diabetes mellitus in the maternal grandmother.,review of systems: , as above.  he says he has had numbness of toes for a long time.  he denies any visual problems.  his legs have been swelling up from time to time for a long time.  he also has history of copd and gets short of breath with minimal activity.  he is also not able to walk due to his weight.  he has had ulcers on his legs, which he gets discharge from.  he has chronic back pain and takes oxycontin.  he denies any constipation, diarrhea, abdominal pain, nausea or vomiting.  there is no chest pain.  he does get short of breath on walking.,physical examination:,the patient is a well-built, obese, white male in no acute distress.,vital signs:  pulse rate of 89 per minute and regular.  blood pressure of 113/69, temperature is 98.4 degrees fahrenheit, and respirations are 18.,heent:  head is normocephalic and atraumatic.  eyes, perrla.  eoms intact.  fundi were not examined.,neck:  supple.  jvp is low.  trachea central.  thyroid small in size.  no carotid bruits.,heart:  shows normal sinus rhythm with s1 and s2.,lungs:  show bilateral wheezes with decreased breath sounds at the bases.,abdomen:  soft and obese.  no masses.  bowel sounds are present.,extremities:  show bilateral edema with changes of chronic venostasis.  he does have some open weeping sores.  pulses could not be palpated due to leg swelling.,impression/plan:,1.  diabetes mellitus, type 2, new onset.  at this time, the patient is on januvia as well as glipizide.  his blood sugar right after eating his supper was 101.  so, i am going to discontinue glipizide, continue on januvia, and add no-concentrated sweets to the diet.  we will continue to follow his blood sugars closely and make adjustments as needed.,2.  neuropathy, peripheral, query etiology.  we will check tsh and b12 levels.,3.  lymphedema.,4.  recurrent cellulitis.,5.  obesity, morbid.,6.  tobacco abuse.  he was encouraged to cut his cigarettes down to 5 cigarettes a day.  he says he feels like smoking after meals.  so, we will let him have it after meals first thing in the morning and last thing at night.,7.  chronic venostasis.,8.  lymphedema.  we would check his lipid profile also.,9.  hypertension.,10.  backbone pain, status post back surgery.,11.  status post hernia repair.,12.  status post penile implant and removal.,13.  umbilical hernia repair.",4
"subjective: , i am following the patient today for immune thrombocytopenia.  her platelets fell to 10 on 01/09/07 and shortly after learning of that result, i increased her prednisone to 60 mg a day.  repeat on 01/16/07 revealed platelets up at 43.  no bleeding problems have been noted.  i have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  the patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,physical examination: , vitals:  as in chart.  the patient is alert, pleasant, and cooperative.  she is in no apparent distress.  the petechial areas on her legs have resolved.,assessment and plan: , patient with improvement of her platelet count on burst of prednisone.  we will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  basically thereafter, over time, i may try to sneak it back a little bit further.  she is on medicines for osteoporosis including bisphosphonate and calcium with vitamin d.  we will arrange to have a cbc drawn weekly.,",14
"preoperative diagnoses:,1.  ventilator-dependent respiratory failure.,2.  multiple strokes.,postoperative diagnoses:,1.  ventilator-dependent respiratory failure.,2.  multiple strokes.,procedures performed:,1.  tracheostomy.,2.  thyroid isthmusectomy.,anesthesia: , general endotracheal tube.,blood loss: , minimal, less than 25 cc.,indications:,  the patient is a 50-year-old gentleman who presented to the emergency department who had had multiple massive strokes.  he had required ventilator assistance and was transported to the icu setting.  because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,procedure: , after all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  the patient was brought to the operative suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  the neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  the skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  the patient was prepped and draped in usual fashion.  the surgeons were gowned and gloved.  a vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  at this point, the midline raphe was identified and the strap muscles were separated utilizing the bovie cautery.  once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  a high-riding innominate was not identified.  at this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with bovie cautery.  suture ligation with #3-0 vicryl was then performed on the thyroid gland in a double interlocking fashion.  this cleared a significant portion of the trachea.  the overlying pretracheal fascia was then cleared with use of pressured forceps as well as bovie cautery.  now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  the second tracheal ring was identified.  the bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  at this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  the airway was entered and inferior to the base, window was created.  the anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  at this point, a #8 shiley tracheostomy tube was inserted freely into the tracheal lumen.  the balloon was inflated and the ventilator was attached.  he was immediately noted to have return of the co2 waveform and was ventilating appropriately according to the anesthetist.  now, all surgical retractors were removed.  the baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  the tube was further secured around the patient's neck with iv tubing.  finally, a drain sponge was placed.  at this point, procedure was felt to be complete.  the patient was returned to the icu setting in stable condition where a chest x-ray is pending.",12
"indication: , bradycardia and dizziness.,comments:,1.  the patient was monitored for 24 hours.,2.  the predominant rhythm was normal sinus rhythm with a minimum heart rate of 56 beats per minute and the maximum heart rate of 114 beats per minute and a mean heart rate of 86 beats per minute.,3.  there were occasional premature atrial contractions seen, no supraventricular tachycardia was seen.,4.  there was a frequent premature ventricular contraction seen.  between 11:00 a.m. and 11:15 a.m. the patient was in ventricular bigemini and trigemini most of the time.  during rest of the monitoring period, there were just occasional premature ventricular contractions seen.  no ventricular tachycardia was seen.,5.  there were no pathological pauses noted.,6.  the longest rr interval was 1.1 second.,7.  there were no symptoms reported.",2
"preoperative diagnosis: , herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,postoperative diagnosis:,  herniated nucleus pulposus, l5-s1 on the left with severe weakness and intractable pain.,procedure performed:,1.  injection for myelogram.,2.  microscopic-assisted lumbar laminectomy with discectomy at l5-s1 on the left on 08/28/03.,blood loss: , approximately 25 cc.,anesthesia: , general.,position:,  prone on the jackson table.,intraoperative findings:,  extruded nucleus pulposus at the level of l5-s1.,history: , this is a 34-year-old male with history of back pain with radiation into the left leg in the s1 nerve root distribution.  the patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity.  he denied any previous history of back pain or back surgeries.  because of his intractable pain as well as severe weakness in the s1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on.  after an informed consent was obtained, all risks as well as complications were discussed with the patient.  ,procedure detail:  ,he was wheeled back to operating room #5 at abcd general hospital on 08/28/03.  after a general anesthetic was administered, a foley catheter was inserted.,the patient was then turned prone on the jackson table.  all of his bony prominences were well-padded.  at this time, a myelogram was then performed.  after the lumbar spine was prepped, a #20 gauge needle was then used to perform a myelogram.  the needle was localized to the level of l3-l4 region.  once inserted into the thecal sac, we immediately got cerebrospinal fluid through the spinal needle.  at this time, approximately 10 cc of conray injected into the thecal sac.  the patient was then placed in the reversed trendelenburg position in order to assist with distal migration of the contrast.  the myelogram did reveal that there was some space occupying lesion, most likely disc at the level of l5-s1 on the left.  there was a lack of space filling defect on the left evident on both the ap and the lateral projections using c-arm fluoroscopy.  at this point, the patient was then fully prepped and draped in the usual sterile fashion for this procedure for a microdiscectomy.  a long spinal needle was then inserted into region of surgery on the right.  the surgery was going to be on the left.  once the spinal needle was inserted, a localizing fluoroscopy was then used to assure appropriate location and this did confirm that we were at the l5-s1 nerve root region.  at this time, an approximately 2 cm skin incision was made over the lumbar region, dissected down to the deep lumbar fascia.  at this time, a weitlaner was inserted.  bovie cautery was used to obtain hemostasis.  we further continued through the deep lumbar fascia and dissected off the short lumbar muscles off of the spinous process and the lamina.  a cobb elevator was then used to elevate subperiosteally off of all the inserting short lumbar muscles off of the spinous process as well as the lamina on the left-hand side.  at this time, a taylor retractor was then inserted and held there for retraction.  suction as well as bovie cautery was used to obtain hemostasis.  at this time, a small kerrison rongeur was used to make a small lumbar laminotomy to expose our window for the nerve root decompression.  once the laminotomy was performed, a small _______ curette was used to elevate the ligamentum flavum off of the thecal sac as well as the adjoining nerve roots.  once the ligamentum flavum was removed, we immediately identified a piece of disc material floating around outside of the disc space over the s1 nerve root, which was compressive.  we removed the extruded disc with further freeing up of the s1 nerve root.  a nerve root retractor was then placed.  identification of disc space was then performed.  a #15 blade was then inserted and small a key hole into the disc space was then performed with a #15 blade.  a small pituitary was then inserted within the disc space and more disc material was freed and removed.  the part of the annulus fibrosis were also removed in addition to the loose intranuclear pieces of disc.  once this was performed, we removed the retraction off the nerve root and the nerve root appeared to be free with pulsatile visualization of the vasculature indicating that the nerve root was essentially free.,at this time, copious irrigation was used to irrigate the wound.  we then performed another look to see if any loose pieces of disc were extruding from the disc space and only small pieces were evident and they were then removed with the pituitary rongeur.  at this time, a small piece of gelfoam was then used to cover the exposed nerve root.  we did not have any dural leaks during this case.  #1-0 vicryl was then used to approximate the deep lumbar fascia, #2-0 vicryl was used to approximate the superficial lumbar fascia, and #4-0 running vicryl for the subcutaneous skin.  sterile dressings were then applied.  the patient was then carefully slipped over into the supine position, extubated and transferred to recovery in stable condition.  at this time, we are still waiting to assess the patient postoperatively to assure no neurological sequela postsurgically are found and also to assess his pain level.",21
"preoperative diagnosis: , severe tricompartmental osteoarthritis, left knee with varus deformity.,postoperative diagnosis:,  severe tricompartmental osteoarthritis, left knee with varus deformity.,procedure performed:  ,left total knee cemented arthroplasty.,anesthesia: , spinal with duramorph.,estimated blood loss:  ,50 ml.,needle and sponge count:,  correct.,specimens: , none.,tourniquet time:  ,approximately 77 minutes.,implants used:,1.  zimmer nexgen posterior stabilized lps-flex gsf femoral component size d, left.,2.  all-poly patella, size 32/8.5 mm thickness.,3.  prolong highly cross-linked polyethylene 12 mm.,4.  stemmed tibial component, size 2.,5.  palacos cement with antibiotics x2 batches.,indication: , the patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  surgery was indicated to relieve her pain and improve her functional ability.  goal objectives and the procedure were discussed with the patient.  risks and benefits were explained.  no guarantees have been made or implied.  informed consent was obtained.,description of the procedure:  ,the patient was taken to the operating room and once an adequate spinal anesthesia with duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  a nonsterile tourniquet was placed proximally in the thigh.  antibiotics were infused prior to foley catheter insertion.  time-out procedure was called.,a straight longitudinal anterior midline incision was made.  dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  deep fascia was exposed.  the tourniquet was inflated at 300 mmhg prior to the skin incision.  a standard medial parapatellar approach was made.  the quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  incision was then carried down distally and distal arthrotomy was completed.  patellar tendon was well protected.  retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  the knee was exposed very well.  significant tricompartmental osteoarthritis was noted.  the osteophytes were removed with a rongeur.  anterior and posterior cruciate ligaments were excised.  medial and lateral meniscectomies were performed.  medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  the medial compartment was more affected than lateral.  medial ligaments were tied.  retropatellar fat pad was excised.  osteophytes were removed.  using a cobb elevator, the medial soft tissue periosteum envelope was well reflected.,attention was placed for the preparation of the femur.  the trochlear notch was ossified.  a rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the pcl attachment.  the anterior portal was 1 cm anterior to the pcl attachment.  the anterior femoral sizer was positioned keeping 3 degrees of external rotation.  rotation was also verified using the transepicondylar axis and whiteside line.  the pins were positioned in the appropriate holes.  anterior femoral cut was performed after placing the cutting guide.  now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  a distal femoral cut was made which was satisfactory.  a sizer was positioned which was noted to be d.  the 5-in-1 cutting block size d was secured with spring pins over the resected bone.  using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  following this, the cutting block for high-flex knee was positioned taking 2 mm of additional posterior condyle.  using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  the bone with its attached soft tissue was removed.  once the femoral preparation was completed, attention was placed for the preparation of the tibia.  the medial and the lateral collateral ligaments were well protected with a retractor.  the pcl retractor was positioned and the tibia was translated anteriorly.  osteophytes were removed.  the extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  once the alignment was verified in a coronal plane, the tibial em guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  a built-in 7-degree posterior slope was considered with instrumentation.  now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  the resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  the resected surface shows some sclerotic bone medially.  now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  the 12 mm spacer block was satisfactory with good stability in flexion and extension.,attention was now placed for completion of the tibia.  size 2 tibial trial plate was positioned.  appropriate external rotation was maintained with the help of the horseshoe alignment rod.  reference to the tibial crest distally and 2nd toe was considered as before.  the midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  the rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  at this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  the range of motion and stability in both flexion and extension was satisfactory.  no further soft tissue release was indicated.  i was able to achieve 0 degrees of extension and complete flexion of the knee.,attention was now placed for the preparation of the patella.  using a patellar caliper, the thickness was measured to be 21.5 mm.  this gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  using a caliper, the resected patella was measured, which was noted to be 13 mm.  a 32 sizer was noted to accommodate the resected surface very well.  drilling was completed and trial 32 button was inserted without any difficulty.  the tracking was satisfactory.  there was no evidence of any subluxation or dislocation of the patella.  the trial components position was satisfactory.  the alignment and the rotation of all 3 components were satisfactory.  all the trial components were removed and the wound was thoroughly irrigated with pulsavac lavage irrigation mechanical system.  the resected surfaces were dried with a sponge.  two batches of palacos cement were mixed.  the cementing was initiated starting with tibia followed by femur and patella.  excess peripheral cement were removed with the curette and knife.  the knee was positioned in extension with a 12 mm trial liner.  patellar clamp was placed after cementing the all-poly patella.  once the cement was set hard and cured, tourniquet was deflated.  hemostasis was achieved.  the trial 12 mm liner was replaced with definitive prolong highly cross-linked polyethylene liner.  range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  anterior-posterior drawer test was satisfactory.  medial and lateral stability was satisfactory.  patellar tracking was satisfactory.  the wound was thoroughly irrigated.  hemostasis was achieved.  a local cocktail was injected, which included the mixture of 0.25% plain marcaine, 30 mg of toradol, and 4 mg of morphine.  the quadriceps mechanism and distal arthrotomy was repaired with #1 vicryl in figure-of-8 fashion.  the subcutaneous closure was performed in layers using 2-0 vicryl and 0 vicryl followed by 2-0 vicryl proximally.  the skin was approximated with staples.  sterile dressings were placed including xeroform, 4x4, abd, and bias.  the patient was then transferred to the recovery room in a stable condition.  there were no intraoperative complications noted.  she tolerated the procedure very well.",25
"examination: , cardiac catheterization.,procedure performed: , left heart catheterization, lv cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,indication: , syncope with severe aortic stenosis.,complications:,  none.,description of procedure: , after informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  the right groin was prepped and draped in the usual sterile fashion.  after adequate conscious sedation and local anesthesia was obtained, a 6-french sheath was placed in the right common femoral artery and a 8-french sheath was placed in the right common femoral vein.  following this, a 7.5-french swan-ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmhg.  the catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmhg.  the catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmhg.  the pulmonary arterial pressures were noted to be 31/14/21 mmhg.  following this, the catheter was removed, the sheath was flushed and a 6-french jl4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  following this, the catheter was exchanged over the guidewire for 6-french jr4 diagnostic catheter.  we were unable to cannulate the right coronary artery.  therefore, we exchanged for a williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  following this, this catheter was exchanged over a guidewire for a 6-french langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  following this, the catheters were removed.  sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-french angio-seal device.  the patient tolerated the procedure well.  there were no complications.,description of findings: , the left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  the left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  the left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  there is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  the right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  the remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  the left ventricle appears to be normal sized.  the aortic valve is heavily calcified.  the estimated ejection fraction is approximately 60%.  there was 4+ mitral regurgitation noted.  the mean gradient across the aortic valve was noted to be 33 mmhg yielding an aortic valve area of 0.89 cm2.,conclusion:,1.  moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,plan: , the patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to dr kenneth fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.",36
"p.o. box 12345,city, state ,re: examinee : abc,claim number : 12345-67890,date of injury : april 20, 2003,date of examination : august 26, 2003,examining physicians : y z, dc,prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. it is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. it has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,chief complaints: , improved focal lower back pain.,history: , abc is a 26-year-old man who immigrated to this country approximately six years ago. he speaks ""un poquito"" english and an interpreter is provided. he has worked for the last four years at floragon forest products, where he normally functions as a ""stacker."" he indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. he was doing this on april 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. he demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. he did not hit his upper back or neck or shoulders, and only sat down on the step as described. he had ""a little"" pain in his back at that time, but was able to get up and continue working. he completed his shift that day and returned to work the following day. he had the next two days off. he says that his symptoms persisted and increased, and on april 25, 2003, he went to the first choice physicians chiropractic and rehab clinic, where he came under the care of dr. abcd, dc. the file contains an entrance form completed by mr. abc which indicates at the bottom under ""previous occurrence of the same pain"" a notation of ""yes, but it was not really the same, it was just a little and tolerable."" there is an additional note on the side which states ""no pain prior to this injury or on that day, occasional (but low back)."" saw this notation, he says today that he did not state this and that the form was done by ""edna"" at dr. abcd's office.,mr. abc was initially treated three times a week and states that this has now been reduced to twice per week. he does not know how long the chiropractic treatment is to continue. initially, he has been seen by dr. xyz on three occasions, the last being on august 15, 2003. dr. xyz has basically referred him back to dr. abcd for continued chiropractic management.,mr. abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. he does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. he denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. he does not participate physically in any sports or hobbies that would be a factor.,present complaints: , mr. abc indicates at this time that he is overall better in that initially he had difficulty ""moving."" he grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. he now has ""good and bad days"" which depends on his activity level noting that he is better over the weekend. he localizes his pain to the midline lumbosacral region. he states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. he occasionally will notice some tightness behind both knees, but again no radicular type of distribution. he denies any focal muscular weakness or sphincter disturbance. his quality of the pain at this time is a ""tightness"" which bothers him, again, primarily with bending at the waist and lifting. he is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,past history: , mr. abc denies any prior similar complaints or treatments. he denies any previous specific lower back injury. he has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. he has seasonal allergies only with no known drug hypersensitivities. he has not been hospitalized overnight and has had no surgeries in his life. he currently takes otc advil and tylenol for lower back pain, but no prescriptive medication. he does not smoke, drink, or use street drugs of any type. review of systems and family history are generally noncontributory.,socio-economic history: , mr. abc, as indicated, was born and reared in mexico and immigrated into this country six years ago.,education: he has our equivalent of a high school education in mexico with no additional formal education in united states.,military history: he has no military experience in his life.,work history: he currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. he is not receiving any workers compensation or other benefits at this time.,physical examination: , abc presents as a cooperative and straightforward 26-year-old hispanic male. he has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. he is right hand dominant. he is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. he did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. lumbar lordosis is normal. he ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,active lumbar ranges of motion with double inclinometer are:,flexion 70 degrees.,extension 20 degrees.,side bending symmetric at 28 degrees.,he complains of lower back pain at the extremes of flexion only. motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. babinski's are neutral, and there is no clonus.,manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. cross leg with rotation hip joint motion is full on either side without reported hip or back pain. hip flexion is symmetric at 130 degrees, again without complaint. leg lengths appeared visually symmetric. mid calf girth is 11-1/2 inches bilaterally. five inches above the knees measured 13 inches right and left. the seated slr is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,in the prone position, he has good gluteal strength on either side with yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. no sacroiliac fixation is identified. hibbs test is negative on either side.,on palpation, he reports midline tenderness at l5-s1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. he indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. no definitive muscular spasm is noted in the lumbar paraspinal musculature.,mr. abc tolerated the examination process without apparent or expressed ill effect. ,imaging studies:,  ap and lateral lumbar/pelvic views dated may 15, 2003 are reviewed. the films are negative for recent fracture or pathology. there appears to be a transitional lumbosacral area with a spatulated transverse process of l1 and slight narrowing of the lumbosacral disc space. no additional abnormalities are identified. the hip and sacroiliac articulations appear well preserved. disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. soft tissue appeared normal without paraspinal mass or abnormality.,diagnosis: , lumbosacral contusion/strain relative to the april 20, 2003 industrial accident - objectively resolved.,summary: , discussion and recommendations in response to questions posed in your august 15, 2003 letter:,1. what is your diagnosis of the worker's condition as a result of the injury? please provide objective medical findings that support your diagnosis. please indicate if the objective findings are reproducible, measurable, or observable, and how.,the diagnosis of the workers condition secondary to the described april 20, 2003 fall is by history a lumbosacral contusion/strain. this impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. in your opinion, is the work injury a contributing cause of the diagnosis? if so, is the work injury the material contributing cause of the diagnosis? please provide an explanation for your opinion.,it would appear that the work injury was the major contributing cause of the diagnosis.,3. are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).",18
"preoperative diagnoses:,  chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,postoperative diagnoses:,  chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,operation: , bilateral myringotomies, insertion of pe tubes, and pharyngeal anesthesia.,anesthesia:  ,general via facemask.,estimated blood loss: , none.,complications: , none.,indications:  ,the patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,procedure: , the patient was brought to the operating room, was placed in supine position.  general anesthesia was begun via face mask technique.  once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  a small amount of wax was removed with a loop.  a 4-mm operating speculum was then introduced.  an anteroinferior quadrant radial myringotomy was then performed.  a large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  reuter bobbin pe tube was then inserted, followed by floxin otic drops and a cotton ball in the external meatus.  head was then turned to the opposite side, where similar procedure was performed.  once again, the middle ear cleft had a mucoid effusion.  a tube was inserted to an anteroinferior quadrant radial myringotomy.,anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.",36
"procedure note:,  the patient was placed in a prone position.  the neck was sterilely prepped using a cervical prep set.  a lidocaine skin wheal was raised over the c5-6 interspace.  a 20-gauge tuohy needle was used.  loss of resistance was obtained using hanging drop technique.  this was followed by 2 ml of radiograph contrast material which showed spread of the dye into the epidural space.  a total of 5 ml containing 4 ml of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated.  following the infiltration, the patient noted warming of his arms and dramatic improvement of his symptoms.  he was observed for 30 minutes and discharged home in good condition.  there were no apparent complications to the procedure.",26
"exam: , ct abdomen and pelvis with contrast ,reason for exam:, nausea, vomiting, diarrhea for one day.  fever.  right upper quadrant pain for one day.  ,comparison: , none. ,technique:,  ct of the abdomen and pelvis performed without and with approximately 54 ml isovue 300 contrast enhancement.  ,ct abdomen: , lung bases are clear.  the liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable.  the aorta is normal in caliber.  there is no retroperitoneal lymphadenopathy.  ,ct pelvis: , the appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change.  per ct, the colon and small bowel are unremarkable.  the bladder is distended.  no free fluid/air.  visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,impression:,1.  unremarkable exam; specifically no evidence for acute appendicitis. ,2.  no acute nephro-/ureterolithiasis. ,3.  no secondary evidence for acute cholecystitis.,results were communicated to the er at the time of dictation.",31
"chief complaint:,  rule out obstructive sleep apnea syndrome.,sample patient is a pleasant, 61-year-old, obese, african-american male with a past medical history significant for hypertension, who presents to the outpatient clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years.  he denies any gasping, choking, or coughing episodes while asleep at night.  his bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed.  he has two to three episodes of nocturia per night.  he denies any morning symptoms.  he has mild excess daytime sleepiness manifested by dozing off during boring activities.,past medical history:,  hypertension, gastritis, and low back pain.,past surgical history:,  turp.,medications:,  hytrin, motrin, lotensin, and zantac.,allergies:,  none.,family history:,  hypertension.,social history:,  significant for about a 20-pack-year tobacco use, quit in 1991.  no ethanol use or illicit drug use.  he is married.  he has one dog at home.  he used to be employed at budd automotors as a die setter for about 37 to 40 years.,review of systems:,  his weight has been steady over the years.  neck collar size is 17½"".  he denies any chest pain, cough, or shortness of breath.  last chest x-ray within the past year, per his report, was normal.,physical exam:,  a pleasant, obese, african-american male in no apparent respiratory distress.  t:  98.  p:  90.  rr:  20.  bp:  156/90.  o2 saturation:  97% on room air.  ht:  5' 5"".  wt:  198 lb.  heent:  a short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no jvd.  cardiac:  regular rate and rhythm without any adventitious sounds.  chest:  clear lungs bilaterally. abdomen:  an obese abdomen with active bowel sounds.  extremities:  no cyanosis, clubbing, or edema.  neurologic:  non-focal.,impression:,1.  probable obstructive sleep apnea syndrome.,2.  hypertension.,3.  obesity.,4.  history of tobacco use.,plan:,1.  we will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2.  encouraged weight loss.,3.  check tsh.,4.  asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5.  asked to return to the clinic one week after sleep the study is done.",4
"indications:  ,chest pain.,stress technique:,",2
"history of present illness: , the patient presents today as a consultation from dr. abc's office regarding the above.  he has history of neurogenic bladder, and on intermittent self-catheterization 3 times a day.  however, june 24, 2008, he was seen in the er, and with fever, weakness, possible urosepsis.  he had a blood culture, which was positive for staphylococcus epidermidis, as well as urine culture noted for same bacteria.  he was treated on iv antibiotics, dr. xyz also saw the patient.  discharged home.  not taking any antibiotics.  today in the office, the patient denies any dysuria, gross hematuria, fever, chills.  he is catheterizing 3 times a day, changing his catheter weekly.  does have history of renal transplant, which has been followed by dr. x and is on chronic steroids.  renal ultrasound, june 23, 2008, was noted for mild hydronephrosis of renal transplant with fluid in the pericapsular space.  creatinine, july 7, 2008 was 2.0, bun 36, and patient tells me this is being followed by dr. x.  no interval complaints today, no issues with catheterization or any gross hematuria.,impression:  ,1.  neurogenic bladder, in a patient catheterizing himself 3 times a day, changing his catheter 3 times a week, we again reviewed the technique of catheterization, and he has no issues with this.,2.  recurrent urinary tract infection, in a patient who has been hospitalized twice within the last few months, he is on steroids for renal transplant, which has most likely been overall reducing his immune system.  he is asymptomatic today.  no complaints today.,plan:,  following a detailed discussion with the patient, we elected to proceed with intermittent self-catheterization, changing catheter weekly, and technique has been discussed as above.  based on the recent culture, we will place him on keflex nighttime prophylaxis, for the next three months or so.  he will call if any concerns.  follow up as previously scheduled in september for re-assessment.  all questions answered.  the patient is seen and evaluated by myself.",4
"preoperative diagnosis:,  critical left carotid stenosis.,postoperative diagnosis: , critical left carotid stenosis.,procedure performed:,  left carotid endarterectomy with endovascular patch angioplasty.,anesthesia:,  cervical block.,gross findings:  ,the patient is a 57-year-old black female with chronic renal failure.  she does have known critical carotid artery stenosis.  she wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by dr. x to perform cardiac catheterization.  she was admitted to the hospital yesterday with chest pain.  she has been considered for coronary artery bypass grafting.  i have been asked to address the carotid stenosis, left being more severe, this was addressed first.  intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  the internal carotid artery is quite torturous.  the external carotid artery was occluded at its origin.  when the endarterectomy was performed, the external carotid artery back-bled nicely.  the internal carotid artery had good backflow bleeding noted.,operative procedure: , the patient was taken to the or suite and placed in the supine position.  then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  during the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  there was some inflammation above the carotid bulb, but this was not problematic.,the patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  the internal carotid artery is controlled with heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with heifitz clips.  the common carotid artery was controlled with profunda clamp.  the patient remained neurologically intact.  a longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  this was extended across the lobe on to the internal carotid artery.  an endarterectomy was then performed.  the ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  as mentioned before, the internal carotid artery is quite torturous.  this was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 prolene suture.,the wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  this was cut to shape and length.  this was sutured in place with continuous running #6-0 prolene suture.  the suture line began at both sites.  the suture was tied in the center along the anterior and posterior walls.  prior to completing the closure, the common carotid artery was flushed.  the internal carotid artery permitted to back bleed.  the clamp was placed after completing the closure.  the clamp was placed at the origin of the internal carotid artery.  flow was first directed into the external carotid artery then into the internal carotid artery.  the patient remained neurologically intact.  topical ________ gelfoam was utilized.  of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  the wound was copiously irrigated with antibiotic solution.  sponge, needle, and all counts were correct.  all surgical sites were inspected.  good hemostasis noted.  the incision was closed in layers with absorbable suture.  stainless steel staples approximated skin.  sterile dressings were applied.  the patient tolerated the procedure well, grossly neurologically intact.",36
"reason for consultation: , glioma.,history of present illness:,  the patient is a 71-year-old woman who was initially diagnosed with a brain tumor in 1982.  she underwent radiation therapy for this, although craniotomy was not successful for a biopsy because of seizure activity during the surgery.  she did well for the next 10 years or so, and developed parkinson disease, possibly related to radiation therapy.  she has been followed by neurology, dr. z, to treat seizure activity.  she has a vagal stimulator in place to help control her seizure activity.,over the last few months, she has had increasing weakness on the right side.  she has been living in a nursing home.  she has not been able to walk, and she has not been able to write for the past three to four years.,mri scan done on 11/13/2006 showed increase in size of the abdominal area and the left parietal region.  there was slight enhancement and appearance was consistent with a medium- to low-grade tumor anterior to the motor cortex.,surgery was performed during this admission to remove some of the posterior part of the tumor.  she tolerated the procedure well.  she has noticed no worsening or improvement in her weakness.  pathology shows a low- to intermediate-grade glioma.  the second opinion by dr. a is still pending.,the patient is feeling well today.  she is not having headache, and reports no new neurologic symptoms.  she has not had leg swelling, cough, shortness of breath, or chest pain.,current medications:  ,1.  ambien p.r.n.  ,2.  vicodin p.r.n.  ,3.  actonel every sunday.  ,4.  colace.  ,5.  felbatol 1200 mg b.i.d.  ,6.  heparin injections for prophylaxis.  ,7.  maalox p.r.n.  ,8.  mirapex 0.5 mg t.i.d.  ,9.  protonix 40 mg daily.  ,10.  tylenol p.r.n.  ,11.  zanaflex 4-mg tablet, one-half tablet daily and 6 mg at bedtime.  ,12.  she has zofran p.r.n., albuterol inhaler q.i.d., and aggrenox, which she is to start.,the rest of the history is mostly from the chart.,allergies: , she is allergic to penicillin.,past medical history:  ,1.  parkinson's, likely secondary to radiation therapy.,2.  history of prior stroke.,3.  seizure disorder secondary to her brain tumor.,4.  history of urinary incontinence.,5.  she has had hip fractures x2, which have required surgical pinning.,6.  appendectomy.,7.  cholecystectomy.,social history:,  shows that she does not smoke cigarettes or drink alcohol.  she lives in a nursing home.,family history:,  shows a family history of breast cancer.,physical examination:,  ,general:  today, she is sitting up in the chair, alert, and appropriate.  she tends to lean towards the right.  the right arm and hand are noticeably weaker than the left.  she is quite thin.,vital signs:  temperature is 98.5, blood pressure is 138/75, pulse is 76, respirations are 16, and pulse oximetry is 92% on room air.,heent:  there is a craniotomy incision on the left parietal region, clean, and dry with stitches still in place.  the oropharynx shows no thrush or mucositis.,lungs:  clear bilaterally to auscultation.,cardiac:  exam shows regular rate.,abdomen:  soft.,extremities:  no peripheral edema or evidence of deep venous thrombosis (dvt) is noted on the lower extremities.,impression and plan:,  progressive low-grade glioma, now more than 20 years since initially diagnosed.  she is status post craniotomy for debulking and has done well with the surgery.,we reviewed the phase ii trials that have used temodar in the setting of grade 2 gliomas.  although, complete responses are rare, it is quite common to have partial response and/or stable disease, and most patients had improved quality of life indices including many patients who benefit from decreased seizure activity.  we discussed using temodar after she heals from her surgery.  toxicities would include fatigue, nausea, and myelosuppression primarily.",4
"nerve conduction studies:,  bilateral ulnar sensory responses are absent.  bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  the left radial sensory response is normal and robust.  left sural response is absent.  left median motor distal latency is prolonged with attenuated evoked response amplitude.  conduction velocity across the forearm is mildly slowed.  right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  the left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  conduction velocities across the forearm and across the elbow are prolonged.  conduction velocity proximal to the elbow is normal.  the right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  there is mild diminution of response around the elbow.  conduction velocity slows across the elbow.  the left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  f-waves are prolonged.,needle emg: , needle emg was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  it revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  there were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,impression: , this electrical study is abnormal.  it reveals the following:,1.  a sensory motor length-dependent neuropathy consistent with diabetes.,2.  a severe left ulnar neuropathy.  this is probably at the elbow, although definitive localization cannot be made.,3.  moderate-to-severe left median neuropathy.  this is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  right ulnar neuropathy at the elbow, mild.,5.  right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  a left c8 radiculopathy (double crush syndrome).,7.  there is no evidence for thoracic radiculitis.,the patient has made very good response with respect to his abdominal pain since starting neurontin.  he still has mild allodynia and is waiting for authorization to get insurance coverage for his lidoderm patch.  he is still scheduled for mri of c-spine and t-spine.  i will see him in followup after the above scans.",28
"preoperative diagnosis: , low back pain.,postoperative diagnosis: , low back pain.,procedure: , lumbar epidural steroid injection, l5-s1.,anesthesia: , local.,special equipment: , fluoroscopic unit.,details of procedure: , the patient was taken to the radiology suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with betadine solution.  the lumbar area was then draped with sterile towels and sterile drapes.  the surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection.  the fluoroscopy x-ray unit was then brought into the sterile field for a pa x-ray visualization of the spine.  a steinmann pin was then placed across the spine to localize the level of the planned injection.  local infiltration using 0.5% preservative-free xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue.  a tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues.  continuous injection of 0.5% preservative-free xylocaine was used during the advancement of the tuohy needle into the deeper spinous tissues.  a solution of 80 mg of depo-medrol with 2 cc of 1% xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.",26
"preoperative diagnoses:  ,1.  cervical spondylosis c5-c6 greater than c6-c7 (721.0).,2.  neck pain, progressive (723.1) with right greater than left radiculopathy (723.4).,postoperative diagnoses:  ,1.  cervical spondylosis c5-c6 greater than c6-c7 (721.0).,2.  neck pain, progressive (723.1) with right greater than left radiculopathy (723.4), surgical findings confirmed.,procedures:  ,1.  anterior cervical discectomy at c5-c6 and c6-c7 for neural decompression (63075, 63076).,2.  anterior interbody fusion at c5-c6 and c6-c7 (22554, 22585) utilizing bengal cages x2 (22851).,3.  anterior instrumentation by uniplate construction c5, c6, and c7 (22845); with intraoperative x-ray x2.,anesthesia:  ,general.,operations: , the patient was brought to the operating room and placed in the supine position where general anesthesia was administered.  then the anterior aspect of the neck was prepped and draped in the routine sterile fashion.  a linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected in a subplatysmal manner and then with only blunt dissection, the prevertebral space was encountered and localizing intraoperative x-ray was obtained once cauterized the longus colli muscle bilaterally allowed for the placement along its mesial portion of self-retaining retractors for exposure of tissues.  prominent anterior osteophytes once identified and compared to preoperative studies were removed at c5-c6 and then at c6-c7 with rongeur, allowing for an annulotomy with an #11 blade through collapsed disc space at c5-6, and even more collapsed at c6-c7.  gross instability appeared and though minimally at both interspaces and residual disc were removed then with the straight disc forceps providing a discectomy at both levels, sending to pathology in a routine fashion as disc specimen.  this was sent separately and allowed for residual disc removal of power drill where drilling extended in normal cortical and cancellous elements of the c5 and c6 interspaces and at c6-c7 removing large osteophytes and process, residual osteophytes from which were removed finally with 1 and 2 mm micro kerrison rongeurs allowing for excision of other hypertrophied ligament posteriorly as well.  this allowed for the bulging into the interspace of the dura, sign of decompressed status, and this was done widely bilaterally to decompress the nerve roots themselves and this was assured by inspection with a double ball dissector as needed.  at no time during the case was there evidence of csf leakage and hemostasis was well achieved with pledgets of gelfoam and subsequently removed with copious amounts of antibiotic irrigation as well as surgifoam.  once hemostasis well achieved, bengal cage was filled with the patient's own bone elements of appropriate size, and this was countersunk into position and quite tightly applied it at first c5-c6, then secondly at c6-c7.  these were checked and found to be well applied and further stability was then added by placement nonetheless of a uniplate of appropriate size.  the appropriate size screws and post-placement x-ray showed well-aligned elements and removal of osteophytes, etc.  the wound was again irrigated with antibiotic solution, inspected, and finally closed in a multiple layered closure by approximation of platysma with interrupted #3-0 vicryl and the skin with subcuticular stitch of #4-0 vicryl incorporating a penrose drain from vertebral space externally through the skin wound and safety pin, and later incorporated itself into sterile bandage.,once the bandage was placed, the patient was taken, extubated from the operating room to the recovery area, having in stable, but guarded condition.  at the conclusion of the case, all instrument, needle, and sponge counts were accurate and correct.  there were no intraoperative complications of any type.",21
"reason for consultation: , i was asked by dr. x to see the patient in consultation for a new diagnosis of colon cancer.,history of present illness:,  the patient presented to medical attention after she noticed mild abdominal cramping in february 2007.  at that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  unfortunately, she had miscarriage at about seven weeks.  she again had abdominal cramping, severe, in late march 2007.  she underwent colonoscopy on 04/30/2007 by dr. y.  of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,on colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  she was not able to have the scope passed past this lesion.  pathology showed a colon cancer, although i do not have a copy of that report at this time.,she had surgical resection done yesterday.  the surgery was laparoscopic assisted with anastomosis.  at the time of surgery, lymph nodes were palpable.,pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  there was no angiolymphatic invasion noted.  radial margin was 0.1 mm.  other margins were 5 and 6 mm.  testing for microsatellite instability is still pending.,staging has already been done with a ct scan of the chest, abdomen, and pelvis.  this showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  the degenerative changes were noted at l5-s1.  the ovaries were normal.  an intrauterine device (iud) was present in the uterus.,review of systems:,  she has otherwise been feeling well.  she has not had fevers, night sweats, or noticed lymphadenopathy.  she has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  she was eating well up until the time of her surgery.  she is up-to-date on mammography, which will be due again in june.  she has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (cns) disease.,allergies: , penicillin, which caused hives when she was a child.,medications prior to admission:,  none.,past medical history: , no significant medical problem.  she has had three miscarriages, all of them at about seven weeks.  she has no prior surgeries.,social history:  ,she smoked cigarettes socially while in her 20s.  a pack of cigarettes would last for more than a week.  she does not smoke now.  she has two glasses of wine per day, both red and white wine.  she is married and has no children.  an iud was recently placed.  she works as an esthetician.,family history:  ,father died of stage iv colon cancer at age 45.  this occurred when the patient was young and she is not sure of the rest of the paternal family history.  she does believe that aunts and uncles on that side may have died early.  her brother died of pancreas cancer at age 44.  another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  otherwise, he has no medical problem.  mother is aged 82 and healthy.  she was recently diagnosed with hemochromatosis.,physical examination: , ,general:  she is in no acute distress.,vital signs:  the patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 l of oxygen by nasal cannula.,skin:  warm and dry.  she has no jaundice.,lymphatics:  no cervical or supraclavicular lymph nodes are palpable.,lungs:  there is no respiratory distress.,cardiac:  regular rate.,abdomen:  soft and mildly tender.  dressings are clean and dry.,extremities:  no peripheral edema is noted.  sequential compression devices (scds) are in place.,laboratory data:,  white blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, mcv is 99.6.  sodium is 136, potassium 4.1, bicarb 25, chloride 104, bun 5, creatinine 0.7, and glucose is 133.  calcium is 8.8 and magnesium is 1.8.,impression and plan: , newly diagnosed stage ii colon cancer, with a stage t3c, n0, m0 colon cancer, grade 1.  she does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,a lengthy discussion was held with the patient regarding her diagnosis and prognosis.  firstly, she has a good prognosis for being cured without adjuvant therapy.  i would consider her borderline for chemotherapy given her young age.  referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (x-linked agammaglobulinemia (xla) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  chemotherapy with 5-fu based regimen would have a smaller benefit of around 2.5%.,plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  we did not review all that information today.,she has a family history of early colon cancer.  her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  tumor is being tested for microsatellite instability and we will discuss this when those results are available.  she has one sibling and he is up-to-date on colonoscopy.  she does report multiple tubes of blood were drawn prior to her admission.  i will check with dr. y's office whether she has had a cea and liver-associated enzymes assessed.  if not, those can be drawn tomorrow.",15
"chief complaint: , right shoulder pain.,history: , the patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02.  she formerly worked for veteran's home as a cna.  she has had a long drawn out course of treatment for this shoulder.  she tried physical therapy without benefit and ultimately came to a subacromion decompression in november 2002.  she had ongoing pain and was evaluated by dr. x who felt that she had a possible brachial plexopathy.  he also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms.  he then referred her to abcd who did emg testing, demonstrating a right suprascapular neuropathy although a c5 radiculopathy could not be ruled out.  mri testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03.  she finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by dr. x.  she comes to me for impairment rating.  she has no chronic health problems otherwise, fevers, chills, or general malaise.  she is not working.  she is right-hand dominant.  she denies any prior history of injury to her shoulder.,past medical history:,  negative aside from above.,family history: , noncontributory.,social history:  ,please see above.,review of systems:,  negative aside from above.,physical examination:  ,a pleasant, age appropriate woman, moderately overweight, in no apparent distress.  normal gait and station, normal posture, normal strength, tone, sensation and deep tendon reflexes with the exception of 4+/5 strength in the supraspinatus musculature on the right.  she has decreased motion in the right shoulder as follows.  she has 160 degrees of flexion, 155 degrees of abduction, 35 degrees of extension, 25 degrees of adduction, 45 degrees of internal rotation and 90 degrees of external rotation.  she has a positive impingement sign on the right.,assessment:,  right shoulder impingement syndrome, right suprascapular neuropathy.,discussion: , with a reasonable degree of medical certainty, she is at maximum medical improvement and she does have an impairment based on ama guide to the evaluation of permanent impairment, fifth edition.  the reason for this impairment is the incident of 01/01/02.  for her suprascapular neuropathy, she is rated as a grade iv motor deficit which i rate as a 13% motor deficit.  this is multiplied by a maximum upper extremity impairment for involvement of the suprascapular nerve of 16% which produces a 2% impairment of the upper extremity when the two values are multiplied together, 2% impairment of the upper extremity.  for her lack of motion in the shoulder she also has additional impairment on the right.  she has a 1% impairment of the upper extremity due to lack of shoulder flexion.  she has a 1% impairment of the upper extremity due to lack of shoulder abduction.  she has a 1% impairment of the upper extremity due to lack of shoulder adduction.  she has a 1% impairment of the upper extremity due to lack of shoulder extension.  there is no impairment for findings in shoulder external rotation.  she has a 3% impairment of the upper extremity due to lack of shoulder internal rotation.  thus the impairment due to lack of motion in her shoulder is a 6% impairment of the upper extremity.  this combines with the 2% impairment of the upper extremity due to weakness in the suprascapular nerve root distribution to produce an 8% impairment of the upper extremity which in turn is a 5% impairment of the whole person based on the ama guide to the evaluation of permanent impairment, fifth edition, stated with a reasonable degree of medical certainty.",4
"reason for admission: , cholecystitis with choledocholithiasis.,discharge diagnoses: , cholecystitis, choledocholithiasis.,additional diagnoses,1.  status post roux-en-y gastric bypass converted to an open procedure in 01/07.,2.  laparoscopic paraventral hernia in 11/07.,3.  history of sleep apnea with reversal after 100-pound weight loss.,4.  morbid obesity with bmi of 39.4.,principal procedure:,  laparoscopic cholecystectomy with laparoscopy converted to open common bile duct exploration and stone extraction.,hospital course: , the patient is a 33-year-old female admitted with elevated bilirubin and probable common bile duct stone.  she was admitted through the emergency room with abdominal pain, elevated bilirubin, and gallstones on ultrasound with a dilated common bile duct.  she subsequently went for a hida scan to rule out cholecystitis.  gallbladder was filled but was unable to empty into the small bowel consistent with the common bile duct blockage.  she was taken to the operating room that night for laparoscopic cholecystectomy.  we proceeded with laparoscopic cholecystectomy and during the cholangiogram there was no contrast.  it was able to be extravasated into the duodenum with the filling defect consistent with the distal common bile duct stone.  the patient had undergone a roux-en-y gastric bypass but could not receive an ercp and stone extraction, therefore, common bile duct exploration was performed and a stone was extracted.  this necessitated conversion to an open operation.  she was transferred to the medical surgical unit postoperatively.  she had a significant amount of incisional pain following morning, but no nausea.  a jackson-pratt drain, which was left in place in two places showed serosanguineous fluid.  white blood cell count was down to 7500 and bilirubin decreased to 2.1.  next morning she was started on a liquid diet.  foley catheter was discontinued.  there was no evidence of bile leak from the drains.  she was advanced to a regular diet on postoperative day #3, which was 12/09/07.  the following morning she was tolerating regular diet.  her bowels had begun to function, and she was afebrile with her pain control with oral pain medications.  jackson-pratt drain was discontinued from the wound.  the remaining jackson-pratt drain was left adjacent to her cystic duct.  following morning, her laboratory studies were better.  her bilirubin was down to normal and white blood cell count was normal with an h&h of 9 and 26.3.  jackson-pratt drain was discontinued, and she was discharged home.  followup was in 3 days for staple removal.  she was given iron 325 mg p.o. t.i.d. and lortab elixir 15 cc p.o. q.4 h. p.r.n. for pain.",9
"exam:,mri left foot,clinical:, a 49-year-old female with ankle pain times one month, without a specific injury. patient complains of moderate to severe pain, worse with standing or walking on hard surfaces, with tenderness to palpation at the plantar aspect of the foot and midfoot region and tenderness over the course of the posterior tibialis tendon.,findings:,received for second opinion interpretations is an mri examination performed on 05/27/2005.,there is edema of the subcutis adipose space extending along the medial and lateral aspects of the ankle.,there is edema of the subcutis adipose space posterior to the achilles tendon. findings suggest altered biomechanics with crural fascial strains.,there is tendinosis of the posterior tibialis tendon as it rounds the tip of the medial malleolus with mild tendon thickening. there is possible partial surface tearing of the anterior aspect of the tendon immediately distal to the tip of the medial malleolus (axial inversion recovery image #16) which is a possible hypertrophic tear less than 50% in cross sectional diameter. the study has been performed with the foot in neutral position. confirmation of this possible partial tendon tear would require additional imaging with the foot in a plantar flexed position with transaxial images of the posterior tibialis tendon as it rounds the tip of the medial malleolus oriented perpendicular to the course of the posterior tibialis tendon.,there is minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths consistent with flexor splinting but intrinsically normal tendons.,normal peroneal tendons.,there is tendinosis of the tibialis anterior tendon with thickening but no demonstrated tendon tear. normal extensor hallucis longus and extensor digitorum tendons.,normal achilles tendon. there is a low-lying soleus muscle that extends to within 2cm of the teno-osseous insertion of the achilles tendon.,normal distal tibiofibular syndesmotic ligamentous complex.,normal lateral, subtalar and deltoid ligamentous complexes.,there are no erosions of the inferior neck of the talus and there are no secondary findings of a midfoot pronating force.,normal plantar fascia. there is no plantar calcaneal spur.,there is venous engorgement of the plantar veins of the foot extending along the medial and lateral plantar cutaneous nerves which may be acting as intermittent entrapping lesions upon the medial and lateral plantar cutaneous nerves.,normal tibiotalar, subtalar, talonavicular and calcaneocuboid articulations.,the metatarsophalangeal joint of the hallux was partially excluded from the field-of-view of this examination.,impression:,tendinosis of the posterior tibialis tendon with tendon thickening and possible surface fraying / tearing of the tendon immediately distal to the tip of the medial malleolus, however, confirmation of this finding would require additional imaging.,minimal synovitis of the flexor digitorum longus and flexor hallucis longus tendon sheaths, consistent with flexor splinting.,edema of the subcutis adipose space along the medial and lateral aspects of the ankle suggesting altered biomechanics and crural fascial strain.,mild tendinosis of the tibialis anterior tendon with mild tendon thickening.,normal plantar fascia and no plantar fasciitis.,venous engorgement of the plantar veins of the foot which may be acting as entrapping lesions upon the medial and lateral plantar cutaneous nerves.",29
"preoperative diagnosis: , chronic renal failure.,postoperative diagnosis:  ,chronic renal failure.,procedure performed:,  insertion of left femoral circle-c catheter.,anesthesia: , 1% lidocaine.,estimated blood loss:,  minimal.,complications: , none.,history: , the patient is a 36-year-old african-american male presented to abcd general hospital on 08/30/2003 for evaluation of elevated temperature.  he was discovered to have a mrsa bacteremia with elevated fever and had tenderness at the anterior chest wall where his perm-a-cath was situated.  he did require a short-term of levophed for hypotension.  he is felt to have an infected dialysis catheter, which was removed.  he was planned to undergo replacement of his perm-a-cath, dialysis catheter, however, this was not possible.  he will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis.  he was explained the risks, benefits, and complications of the procedure previously.  he gave us informed consent to proceed.,operative procedure: , the patient was placed in the supine position.  the left inguinal region was shaved.  his left groin was then prepped and draped in normal sterile fashion with betadine solution.  utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine.  under direct aspiration technique, the left femoral vein was cannulated.  next, utilizing an #18 gauge cook needle, the left femoral vein was cannulated.  sutures were removed, nonpulsatile flow was observed and a seldinger guidewire was inserted within the catheter.  the needle was then removed.  utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter.  utilizing a #10 french dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the seldinger guidewire.  dilator was removed and a preflushed circle-c 8 inch catheter was inserted over the seldinger guidewire.  the guidewire was retracted out from the blue distal port and grasped.  the catheter was then placed in the left femoral vessel _______.  this catheter was then fixed to the skin with #3-0 silk suture.  a mesenteric dressing was then placed over the catheter site.  the patient tolerated the procedure well.  he was turned to the upright position without difficulty.  he will undergo dialysis today per nephrology.",19
"preoperative diagnoses,1.  a 40 weeks 6 days intrauterine pregnancy.,2.  history of positive serology for hsv with no evidence of active lesions.,3.  non-reassuring fetal heart tones.,post operative diagnoses,1.  a 40 weeks 6 days intrauterine pregnancy.,2.  history of positive serology for hsv with no evidence of active lesions.,3.  non-reassuring fetal heart tones.,procedures,1.  vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  repair of the third-degree midline laceration lasting for 25 minutes.,anesthesia: , local.,estimated blood loss: , 300 ml.,complications:  ,none.,findings,1.  live male infant with apgars of 9 and 9.,2.  placenta delivered spontaneously intact with a three-vessel cord.,disposition:  ,the patient and baby remain in the ldr in stable condition.,summary: , this is a 36-year-old g1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  when she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  the baby had a -2 station.  she had no regular contractions.  fetal heart tones were 120s and reactive.  she was started on pitocin for labor induction and labored quite rapidly.  she had spontaneous rupture of membranes with a clear fluid.  she had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  with the rapid cervical change and descent of fetal head, there were some variable decelerations.  the baby was at a +1 station when the patient began pushing.  i had her push to get the baby to a +2 station.  during pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  because of this, i recommended a vacuum delivery for the baby.  the patient agreed.,the baby's head was confirmed to be in the right occiput anterior presentation.  the perineum was injected with 1% lidocaine.  the bladder was drained.  the vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  with the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  the contraction ended.  the vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  with the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  a modified ritgen maneuver was used to stabilize the fetal head.  the vacuum was deflated and removed.  the baby's head then delivered atraumatically.  there was no nuchal cord.  the baby's anterior shoulder delivered after a less than 30 second delay.  no additional maneuvers were required to deliver the anterior shoulder.  the posterior shoulder and remainder of the body delivered easily.  the baby's mouth and nose were bulb suctioned.  the cord was clamped x2 and cut.  the infant was handed to the respiratory therapist.,pitocin was added to the patient's iv fluids.  the placenta delivered spontaneously, was intact and had a three-vessel cord.  a vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  the right side wall laceration was repaired with #3-0 vicryl suture in a running fashion with local anesthesia.  the third-degree laceration was also repaired with #3-0 vicryl sutures.  local anesthesia was used.  the capsule was visible, but did not appear to be injured at all.  it was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 vicryl in the typical fashion.,the patient tolerated the procedure very well.  she remains in the ldr with the baby.  the baby is vigorous, crying and moving all extremities.  he will go to the new born nursery when ready.  the total time for repair of the laceration was 25 minutes.",36
"chief complaint:  ,this 18 year old male presents today with shoulder pain right.  location:  he indicates the problem location is the right shoulder diffusely.  quality:  quality of the pain is described by the patient as aching, throbbing and tolerable.  patient relates pain on a scale from 0 to 10 as 5/10.  severity:  the severity has worsened over the past 3 months.  timing (onset/frequency):  onset was gradual and after pitching a baseball game.  modifying factors:  patient's condition is aggravated by throwing.  he participates with difficulty in basketball.  past conservative treatments include nsaid and muscle relaxant medications.,allergies: , no known medical allergies.,medication history:,  none.,past medical history:  ,childhood illnesses: (+) strep throat (+) mumps (+) chickenpox,past surgical history:,  no previous surgeries.,family history:,  patient admits a family history of arthritis associated with mother.,social history: , patient denies smoking, alcohol abuse, illicit drug use and stds.,review of systems:,musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in am.,psychiatric: (-) psychiatric or emotional difficulties.,eyes: (-) visual disturbance or change.,neurological: (-) neurological symptoms or problems endocrine: (-) endocrine-related symptoms.,allergic / immunologic: (-) allergic or immunologic symptoms.,ears, nose, mouth, throat: (-) symptoms involving ear, nose, mouth, or throat.,gastrointestinal: (-) gi symptoms.,genitourinary: (-) gu symptoms.,constitutional symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,cardiovascular: (-) cardiovascular problems or chest symptoms.,respiratory: (-)breathing difficulties, respiratory symptoms.,physical exam:  bp standing:  116/68 resp:  16 hr:  68 temp:  98.1 height:  5 ft.  11 in.  weight:  165 lbs.  patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  oriented to person, place and time.  right shoulder shows evidence of swelling and tenderness.  radial pulses are 2 /4, bilateral.  brachial pulses are 2 /4, bilateral.,appearance:  normal.,tenderness:  anterior - moderate, biceps - none, posterior - moderate and subacromial - moderate right.,range of motion:  right shoulder rom shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  l shoulder normal.,strength:  external rotation - fair.  internal rotation - poor right.,ac joint:  pain with abd and cross-chest - mild right.,rotator cuff:  impingement - moderate.  painful arc - moderate right.,instability:  none.,test & x-ray results:,  x-rays of the shoulder were performed.  x-ray of right shoulder reveals cuff arthropathy present.,impression: , rotator cuff syndrome, right.,plan: , diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  i noted that this is a very common condition resulting in significant difficulties with use of the arm.  several treatment options and their potential benefits were described.  nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  cortisone shots can be very effective and are quite safe.  often more than one injection may be required.  physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  if these treatments fail to resolve symptoms, an mri or shoulder arthrogram may be required to rule out a rotator cuff tear.  injected shoulder joint and with celestone soluspan 1.0 cc .  ordered x-rays of shoulder right.,prescriptions:,  vioxx dosage:  25 mg tablet sig:  tid dispense:  60 refills:  0 allow generic:  yes,patient instructions:,  patient was instructed to restrict activity.  patient was given instructions on rice therapy.",4
"procedure: , bilateral l5 dorsal ramus block and bilateral s1, s2, and s3 lateral branch block.,indication: , sacroiliac joint pain.,informed consent: , the risks, benefits and alternatives of the procedure were discussed with the patient.  the patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,the risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and cns side effects with possible vascular entry of medications.  i also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,the patient was informed both verbally and in writing.  the patient understood the informed consent and desired to have the procedure performed.,procedure:  ,oxygen saturation and vital signs were monitored continuously throughout the procedure.  the patient remained awake throughout the procedure in order to interact and give feedback.  the x-ray technician was supervised and instructed to operate the fluoroscopy machine.,the patient was placed in the prone position on the treatment table, pillow under the chest, and head rotated contralateral to the side being treated.  the skin over and surrounding the treatment area was cleaned with betadine.  the area was covered with sterile drapes, leaving a small window opening for needle placement.  fluoroscopic pillar view was used to identify the bony landmarks of the sacrum and sacroiliac joint and the planned needle approach.  the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine.,with fluoroscopy, a 25-gauge 3.5-inch spinal needle was gently guided into the groove between the sap and sacrum through the dorsal ramus of the l5 and the lateral and superior border of the posterior sacral foramen with the lateral branches of s1, s2, and s3.  multiple fluoroscopic views were used to ensure proper needle placement.  approximately 0.25 ml of nonionic contrast agent was injected showing no concurrent vascular dye pattern.  finally, the treatment solution, consisting of 0.5% of bupivacaine was injected to each area.  all injected medications were preservative free.  sterile technique was used throughout the procedure.,additional details: , this was then repeated on the left side.,complications: , none.,discussion:  ,postprocedure vital signs and oximetry were stable.  the patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  the patient was told to resume all medications.  the patient was told to resume normal activities.,the patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes or changes in bowel or bladder function.,follow up appointment was made at the pm&r spine clinic in approximately 1 week.",25
"reason for consultation: , left flank pain, ureteral stone.,brief history: , the patient is a 76-year-old female who was referred to us from dr. x for left flank pain.  the patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  the patient has had pain in the abdomen and across the back for the last four to five days.  the patient has some nausea and vomiting.  the patient wants something done for the stone.  the patient denies any hematuria, dysuria, burning or pain.  the patient denies any fevers.,past medical history: , negative.,past surgical history:  ,years ago she had surgery that she does not recall.,medications: , none.,allergies: , none.,review of systems: , denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  the patient does have a history of nausea and vomiting, but is doing better.,physical examination:,vital signs:  the patient is afebrile.  vitals are stable.,heart:  regular rate and rhythm.,abdomen:  soft, left-sided flank pain and left lower abdominal pain.,the rest of the exam is benign.,laboratory data: , white count of 7.8, hemoglobin 13.8, and platelets 234,000.  the patient's creatinine is 0.92.,assessment:,1.  left flank pain.,2.  left ureteral stone.,3.  nausea and vomiting.,plan: , plan for laser lithotripsy tomorrow.  options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  the patient has a pretty enlarged stone.  failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  the patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  the patient understood all the risk, benefits of the procedure and wanted to proceed.  need for stent was also discussed with the patient.  the patient will be scheduled for surgery tomorrow.  plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for kub to evaluate for the exact location of the stone prior to surgery tomorrow.",14
"the patient presented in the early morning hours of february 12, 2007, with contractions.  the patient was found to be in false versus early labor and managed as an outpatient.  the patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  there was minimal cervical dilation, but 80% effacement by nurse examination.  the patient was admitted.  expected management was utilized initially.  stadol was used for analgesia.  examination did not reveal vulvar lesions.  epidural was administered.  membranes ruptured spontaneously.  cervical dilation progressed.  acceleration-deceleration complexes were seen.  overall, fetal heart tones remained reassuring during the progress of labor.  the patient was allowed to ""labor down"" during second stage.  early decelerations were seen as well as acceleration-deceleration complexes.  overall, fetal heart tones were reassuring.  good maternal pushing effort produced progressive descent.,spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  there was no loop or coil of cord.  infant was vigorous female sex.  oropharynx was aggressively aspirated.  cord blood was obtained.  placenta delivered spontaneously.,following delivery, uterus was explored without findings of significant tissue.  examination of the cervix did not reveal lacerations.  upper vaginal lacerations were not seen.  multiple first-degree lacerations were present.  specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  all mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 vicryl with the knots being buried.  post-approximation examination of the rectum showed smooth, intact mucosa.  blood loss with the delivery was 400 ml.,plans for postpartum care include routine postpartum orders.  nursing personnel will be notified of gilbert's syndrome.",36
"reason for neurological consultation:,  muscle twitching, clumsiness, progressive pain syndrome, and gait disturbance.,history of present illness: , the patient is a 62-year-old african-american male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two mis, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001.  he states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands.  more recently, he describes a burning sensation along with numbness.  this has become a particular problem and of all the problems he has he feels that pain is his primary concern.  over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands.  he denies any weakness per se, just clumsiness and decreased sensation.  he has also been complaining of brief muscle jerks, which occur in both hands and his shoulders.  this has been a fairly longstanding problem, and again has become more prevalent recently.  he does not have any tremor.  he denies any neck pain.  he walks with the aid of a walker because of unsteadiness with gait.,recently, he has tried gabapentin, but this was not effective for pain control.  oxycodone helps somewhat and gives him at least three hours pain relief.  because of the pain, he has significant problems with fractured sleep.  he states he has not had a good night's sleep in many years.  about six months ago, after an mi and pacemaker insertion, he was transferred to a nursing facility.  at that facility, his insulin was stopped.  since then he has only been on oral medication for his diabetes.  he denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms., ,past medical history: , diabetes, hypertension, coronary artery disease, stroke, arthritis, gerd, and headaches.,medications: , trazodone, simvastatin, hydrochlorothiazide, prevacid, lisinopril, glipizide, and gabapentin.,family history: , discussed above and documented on the chart.,social history: , discussed above and documented on the chart.  he does not smoke.  he lives in a senior citizens building with daily nursing aids.  he previously was a security guard, but is currently on disability.,review of systems: , discussed above and documented on the chart.,physical examination: , on examination, blood pressure 150/80, pulse of 80, respiratory rate 22, and weight 360 pounds.  pain scale 7/10.  a full general and neurological examination was performed on the patient and is documented on the chart.,the patient is obese with significant ankle edema.,neurological examination reveals normal cognitive exam and normal cranial nerve examination.  motor examination reveals mild atrophy in bilateral fdis, but still has a strong grip.  individual muscle strength is close to normal with only subtle weakness found in ankle plantar and dorsiflexion.  tone and bulk are normal.  sensory examination reveals a severe decrease to all modalities in his lower extremities from just above the knees distally.  he has no vibration sense at his knees.  similarly, there is decrease to all sensory modalities in his both upper extremities from just above the wrist distally.  the only reflexes i could obtain with trace reflexes in his biceps.  remaining reflexes were unelicitable.  no babinski.  the patient walks normally with the aid of a cane.  he has severe sensory ataxia with inability to walk unaided.  positive romberg with eyes open and closed.,impression and plan:,1.  probable painful diabetic neuropathy.  symptoms are predominantly sensory and severely dysfunctioning, with the patient having inability to ambulate independently as well as difficulty with grip and temperature differentiation in his upper extremities.  he has relative preservation of motor function.  because these symptoms are progressive and, by report, he came off his insulin, suggesting somewhat mild diabetes, i would like to rule out other causes of progressive neuropathy.,2.  he has history of myoclonic jerks.  i did not see any on my examination today and i feel that these are benign and probably secondary to his severe insomnia, which he states is secondary to the painful neuropathy.  i would like to rule out other causes such as hepatic encephalopathy., ,i have recommended the following:,1.  emg/nerve conduction study to assess severity of neuropathy and to characterize neuropathy.,2.  blood work, looking for other causes of neuropathy and myoclonus, to include cbc, cmp, tsh, lft, b12, rpr, esr, lyme titer, and hba1c, and ammonia level.,3.  neurontin and oxycodone have not been effective, and i have recommended cymbalta starting at 30 mg q.d. for five days and then increasing to 60 mg q.d.  side effect profile of this medication was discussed with the patient.,4.  i have explained to him that progression of diabetic neuropathy is closely related to diabetic control and i have recommended tight diabetic control.,5.  i will see him at followup at the emg.",20
"diagnosis:,  status post brain tumor removal.,history:,  the patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal.  the patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness.  the patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications.  the patient reports that she was admitted to hospital on 12/05/08.  at that time, they found massive swelling on the brain and a second surgery was performed.  the patient then remained in acute rehab until she was discharged to home on 01/05/09.  the patient's husband, al, is also present and he reports that during rehabilitation the patient did have a dvt in the left calf that has since been resolved.,past medical history: , unremarkable.,medications:  ,coumadin, keppra, decadron, and glucophage.,subjective: , the patient reports that the pain is not an issue at this time.  the patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,patient goal:  ,to increase strength in her left leg for better balance and walking.,objective:,range of motion:  bilateral lower extremities are within normal limits.,strength:  bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,balance:  the patient's balance was assessed with a berg balance test.  the patient has got 46/56 points, which places her at moderate risk for falls.,gait:  the patient ambulates with contact guard assist.  the patient ambulates with a reciprocal gait pattern with good bilateral foot clearance.  however, the patient has been reports that with increased fatigue, left footdrop tends to occur.  a 6-minute walk test will be performed at the next visit due to time constraints.,assessment: , the patient is a 64-year-old female referred to physical therapy status post brain surgery.  examination indicates deficits in strength, balance, and ambulation.  the patient will benefit from skilled physical therapy to address these impairments.,treatment plan: , the patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks.  interventions include:,1.  therapeutic exercise.,2.  balance training.,3.  gait training.,4.  functional mobility training.,short term goal to be completed in 4 weeks:,1.  the patient is to tolerate 30 repetitions of all lower extremity exercises.,2.  the patient is to improve balance with a score of 50/56 points.,3.  the patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,long term goal to be achieved in 8 weeks:,1.  the patient is to ambulate independently within her home and standby to general supervision within the community.,2.  berg balance test to be 52/56.,3.  the patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4.  the patient is to demonstrate safely stepping over and around objects without loss of balance.,prognosis for the above-stated goals is good.  the above treatment plan has been discussed with the patient and her husband.  they are in agreement.",20
"preoperative diagnoses: , papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,postoperative diagnoses: , papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,procedure:  ,the patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,findings: , normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,estimated blood loss:  ,approximately 10 ml.,fluids: , crystalloid only.,complications: , none.,drains: , rubber band drain in the neck.,condition:,  stable.,procedure:  ,the patient placed supine under general anesthesia.  first, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and betadine prep.  sterile dressing was placed.  the laryngeal monitoring was noted to be working fine.  then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  the strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  then, using bipolar cautery and a coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the berry ligaments.  the berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the harmonic scalpel and removed.  no bleeding was seen.  there was a small nick in the external jugular vein that was tied with a 4-0 vicryl suture ligature.  after this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  after this was completed, no bleeding was seen.  the laryngeal nerve could be seen and intact and then rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and mastisol and steri-strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  procedure was then terminated at that time.",36
"cc: ,fall with subsequent nausea and vomiting.,hx: ,this 52 y/o rhm initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. he ""knew what he wanted to say, but could not say it."",his speech was slurred and he found it difficult to control his tongue. examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. he could read, but could not write. he exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. he was thougth to have possible pick's disease vs. cortical basal ganglia degeneration.,on 11/18/94, he fell and was seen in neurology clinic on 11/23/94. eeg showed borderline background slowing and no other abnormalities. an mri on 11/8/94, revealed mild atrophy of the left temporal lobe. neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. these were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,he reported consuming 8 beers on the evening of 1/1/95. on 1/2/95, at 9:30am, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. he subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. he was taken to the etc at uihc. skull films were negative and he was treated with iv compazine and iv fluid hydration and sent home. his nausea and vomiting persisted and he became generally weak. he returned to the etc at uihc on 1/5/95. hct scan revealed a right frontal sdh containing signs of both chronic and acute bleeding.,meds:, none.,pmh:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. he reportedly had brief loss of consciousness with no reported head injury.,2)progressive aphasia. in 10/93, he was able to draw blue prints and write checks for his family business, 3) left frontoparietal headache for 1.5 years prior to 10/94. headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,fhx:, no neurologic disease in family.,shx:, divorced and lives with girlfriend. one child by current girlfriend. he has 3 children with former wife. smoked more than 15 years ago. drinks 1-2 beers/day. former iron worker.,exam: ,bp128/83, hr68, rr18, 36.5c. supine: bp142/71, hr64; sitting: bp127/73, hr91 and lightheaded.,ms: appeared moderately distressed and persistently held his forehead. a&o to person, place and time. dysarthric and dysphagic. non-fluent speech and able to say single syllable words such as ""up"" or ""down"". he comprehended speech, but could not repeat or write.,cn: pupils 4/3.5 decreasing to 2/2 on exposure to light. eom were full and smooth. optic disks were flat and without sign of hemorrhage. moderate facial apraxia, but had intact facial sensation.,motor: 5/5 strength with normal muscle bulk and tone.,sensory: no abnormalities noted.,coord: decreased ram in the rue. he had difficulty mmicking movements and postures with his rue,gait: nd.,station: no truncal ataxia, but he had a slight rue upward drift.,reflexes 2/2 bue, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,rectal exam was unremarkable. the rest of the general physical exam was unremarkable.,heent: atraumatic normocephalic skull. no carotid bruitts.,course:, pt, ptt, cbc, gs, ua and skull xr were negative. hct brain, revealed a left frontal sdh with acute and cronic componenets.,he was markedly orthostatic during the first few days of his hospital stay. he was given a 3 day trial of florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. this improved still further with a trial of sigvaris pressure stockings. a second hct was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal sdh. he was discharged home.,his ideomotor apraxia worsened by 1/96. he developed seizures and was treated with cbz. he progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. he was last seen in 10/96 and the working diagnosis was cbgd vs. pick's disease.",20
"reason for consultation: , thyroid mass diagnosed as papillary carcinoma.,history of present illness:  ,the patient is a 16-year-old young lady, who was referred from the pediatric endocrinology department by dr. x for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  the patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  an ultrasound examination had reportedly been done in the past and the mass is being observed.  when it began to enlarge recently, she was referred to the pediatric endocrinology department and had an evaluation there.  the patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  the patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  she has no weight changes consistent with either hyper or hypothyroidism.  there is no family history of thyroid cancer in her family.  she has no notable discomfort with this lesion.  there have been no skin changes.  historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,past medical history:,  essentially unremarkable.  the patient has never been hospitalized in the past for any major illnesses.  she has had no prior surgical procedures.,immunizations: , current and up to date.,allergies: , she has no known drug allergies.,current medications:  ,currently taking no routine medications.  she describes her pain level currently as zero.,family history: , there is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  this was done in tijuana.  his mom is from central portion of mexico.  there is no family history of multiple endocrine neoplasia syndromes.,social history:  ,the patient is a junior at hoover high school.  she lives with her mom in fresno.,review of systems: , a careful 12-system review was completely normal except for the problems related to the thyroid mass.,physical examination:,general:  the patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  she was alert and oriented x3 and had an appropriate affect.,heent:  the head and neck examination is most significant.  there is mild amount of facial acne.  the patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,neck:  there is a slightly visible midline bulge in the region of the thyroid isthmus.  a firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  this mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that i can determine.  there are some shotty adenopathy in the area.  no supraclavicular nodes were noted.,chest:  excursions are symmetric with good air entry.,lungs:  clear.,cardiovascular:  normal.  there is no tachycardia or murmur noted.,abdomen:  benign.,extremities:  extremities are anatomically correct with full range of motion.,genitourinary:  external genitourinary exam was deferred at this time and can be performed later during anesthesia.  this is same as too for her rectal examination.,skin:  there is no acute rash, purpura, or petechiae.,neurologic:  normal and no focal deficits.  her voice is strong and clear.  there is no evidence of dysphonia or vocal cord malfunction.,diagnostic studies: , i reviewed laboratory data from the diagnostics lab, which included a mild abnormality in the ast at 11, which is slightly lower than the normal range.  t4 and tsh levels were recorded as normal.  free thyroxine was normal, and the serum pregnancy test was negative.  there was no level of thyroglobulin recorded on this.  a urinalysis and comprehensive metabolic panel was unremarkable.  a chest x-ray was obtained, which i personally reviewed.  there is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,impression/plan: , the patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  the pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  i spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  during this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  we talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  we also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  i answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  i also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  this will have some impact on the postoperative adjunctive therapy.  the radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  i did discuss with them the possibility of having to take large doses of calcium and vitamin d in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  all of the family's questions have been answered.  this is a very anxious and anxiety provoking time in the family.  i have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  we are tentatively planning on proceeding this upcoming friday afternoon with total thyroidectomy.",27
"history of present illness:,  a 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  he had a ct scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  there was also a question of liver metastases at that time.,operation performed:,  fiberoptic bronchoscopy with endobronchial biopsies.,the bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  the tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  approximately 15 biopsies were taken of the tumor.,attention was then directed at the left upper lobe and lingula.  epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  approximately eight biopsies were taken of the left upper lobe.",2
"allowed conditions:,  left knee strain, meniscus tear left knee.,contested condition:,  osteoarthritis of the left knee.,employer:,  abcd.,i examined xxxxx today september 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee.  he is a 57-year-old assembly worker who was injured on june 13, 2007, which according to his froi was due to ""repairing cars, down on knees to work on concrete floors.""  in addition, he slipped on an air hose on the floor at work on march 7, 2007, re-injuring his left knee.  he developed pain and swelling in his left knee.  he denies having any difficulties with his left knee prior to the injury of june 13, 2002.,diagnostic studies: , august 2, 2002, mri of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade ii to iii chondromalacia of the medial joint space.  on june 26, 2007, mri of his left knee was referred to in the injury management report of june 19, 2007, as showing osteoarthritis of the medial compartment has advanced.  he brought with him copies of x-rays taken july 16, 2007, of his left knee, which i reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella.  there was subluxation of the tibia on the femur with standing.,after his injury, he received treatment from dr. x for patellofemoral syndrome with knee sleeve.  he also received treatment from dr. y also for left knee sprain and patellar pain.  he also did exercise, does use a knee sleeve and aleve.  on december 5, 2002, he underwent arthroscopy of the left knee by dr. z who did a partial resection of a torn medial meniscus.  he also noticed grade iii chondromalacia of the patella as well as the torn medial meniscus.  he states that he was asymptomatic until he slipped on an air hose while at work on march 7, 2007, and again developed pain and swelling in his left knee.  standing aggravates his pain.  he has had one injection of cortisone by dr. z about a month ago, which has helped his pain.  he takes one hydrocodone 7.5/750 mg daily.,examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf.  there was patellar crepitus with knee motion.  there was no motor weakness or reflex changes.  he walked without a limp and could stand on his heels and toes equally well.  there was no instability of the knee and no effusion.  range of motion was 0 to 120 degrees.,question: , xxxxx has recently filed to reactivate this claim.  please give me your opinion as to whether xxxxx's current clinical presentation is related to the industrial injury stated above.,answer:, yes.  his original mri of august 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade ii to iii chondromalacia of the medial joint space, which was the beginning of osteoarthritis.  also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of june 13, 2007, specifically to the torn medial meniscus.,question:  ,do i believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,answer:, yes, i believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,question:,  xxxxx has filed an application for additional allowance of osteoarthritis of the left knee.  based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,answer: ,yes.  please see the discussion in the answer to question no one.  in addition, x-rays of july 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,question: , if you find this condition exists, is it a direct and proximate result of the june 13, 2002, injury?,answer:, yes.  see discussion in answer to question number one.,question: , do you find that xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,answer: ,no.  i believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,question: , in addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to xxxxx's condition?,answer:, no.  he does not give any history of any intervening injuries.,if you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,question:,  based on the objective findings is the request for 10 sessions of physical therapy per c-9 dated july 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,answer:,  yes.,",4
"chief complaint:, nausea and abdominal pain after eating.,gall bladder history:, the patient is a 36 year old white female.  patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. the patient's symptoms have been present for 3 months. complaints are relieved with lying on right side and antacids. prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without cbd obstruction. laboratory studies that are elevated include total bilirubin and elevated wbc.,past medical history:, no significant past medical problems.,past surgical history:, diagnostic laparoscopic exam for pelvic pain/adhesions.,allergies:, no known drug allergies.,current medications:, no current medications.,occupational /social history:, marital status: married. patient states smoking history of 1 pack per day. patient quit smoking 1 year ago. admits to no history of using alcohol. states use of no illicit drugs.,family medical history:, there is no significant, contributory family medical history.,ob gyn history:, lmp: 5/15/1999. gravida: 1. para: 1.  date of last pap smear: 1/15/1998.,review of systems:,cardiovascular: denies angina, mi history, dysrhythmias, palpitations, murmur, pedal edema, pnd, orthopnea, tia's, stroke, amaurosis fugax.,pulmonary: denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, tb exposure or treatment.,neurological: patient admits to symptoms of seizures and ataxia.,skin: denies scaling, rashes, blisters, photosensitivity.,physical examination:,appearance: healthy appearing. moderately overweight.,heent: normocephalic. eom's intact. perrla. oral pharynx without lesions.,neck: neck mobile. trachea is midline.,lymphatic: no apparent cervical, supraclavicular, axillary or inguinal adenopathy.,breast: normal appearing breasts bilaterally, nipples everted.  no nipple discharge, skin changes.,chest: normal breath sounds heard bilaterally without rales or rhonchi.  no pleural rubs. no scars.,cardiovascular: regular heart rate and rhythm without murmur or gallop.,abdominal: bowel sounds are high pitched.,extremities: lower extremities are normal in color, touch and temperature. no ischemic changes are noted. range of motion is normal.,skin: normal color, temperature, turgor and elasticity; no significant skin lesions.,impression diagnosis:  ,  gall bladder disease. abdominal pain.,discussion:, laparoscopic cholecystectomy handout was given to the patient, reviewed with them and questions answered. the patient has given both verbal and written consent for the procedure.,plan:, we will proceed with laparoscopic cholecystectomy with intraoperative cholangiogram.,medications prescribed:,",4
"exam:,  skull, complete, five images,history:,  plagiocephaly.,technique: , multiple images of the skull were evaluated.  there are no priors for comparison.,findings: , multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure.  there is no evidence of any craniosynostosis.  there is no radiographic evidence of plagiocephaly.,impression: , no evidence of craniosynostosis or radiographic characteristics for plagiocephaly.",31
"admitting diagnoses,1.  acute gastroenteritis.,2.  nausea.,3.  vomiting.,4.  diarrhea.,5.  gastrointestinal bleed.,6.  dehydration.,discharge diagnoses,1.  acute gastroenteritis, resolved.,2.  gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,brief h&p and hospital course: , this patient is a 56-year-old male, a patient of dr. x with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time.  this patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse.  the patient was admitted into the er and had trop x1 done, which was negative and ecg showed to be of normal sinus rhythm.,lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count.  upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for clostridium difficile and moderate amount of occult blood and moderate amount of rbcs.  the patient's nausea, vomiting, and diarrhea did resolve during his hospital course.  was placed on iv fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well.  the patient also denied any abdominal pain upon day of discharge.  the patient was also started on prednisone as per gi recommendations.  he was started on 60 mg p.o.  amylase and lipase were also done which were normal and ldh and crp was also done which are also normal and lfts were done which were also normal as well.,plan: , the plan is to discharge the patient home.  he can resume his home medications of prandin, actos, lipitor, glucophage, benicar, and advair.  we will also start him on a tapered dose of prednisone for 4 weeks.  we will start him on 15 mg p.o. for seven days.  then, week #2, we will start him on 40 mg for 1 week.  then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop.  he was instructed to take tapered dose of prednisone for 4 weeks as per the gi recommendations.",13
"procedure: , placement of left ventriculostomy via twist drill.,preoperative diagnosis:,  massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,postoperative diagnosis: , massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,indications for procedure:  ,the patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  his condition is felt to be critical.  in a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  i have discussed this with patient's wife who agrees and asked that we proceed emergently.,after a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  subsequently a 1 cm incision was made over kocher's point.  hemostasis was obtained.  then a twist drill was made over this area.  bones strips were irrigated away.  the dura was perforated with a spinal needle.,a camino monitor was connected and zeroed.  this was then passed into the left lateral ventricle on the first pass.  excellent aggressive very bloody csf under pressure was noted.  this stopped, slowed, and some clots were noted.  this was irrigated and then csf continued.  initial opening pressures were 30, but soon arose to 80 or a 100.,the patient tolerated the procedure well.  the wound was stitched shut and the ventricular drain was then connected to a drainage bag.,platelets and ffp as well as vitamin k have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.",36
"bilateral sacroiliac joint injections,procedure:,:  informed consent was obtained from the patient.  the patient was placed in the prone position.  after preparation and local anesthetic administration, and image intensifier control a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach.  a small amount of contrast material was administered to outline the recesses of the joints.  verification of the initial needle position with contrast administration, 1 ml of solution was administered at this site after aspiration, consisting of 0.5 ml of 0.25% marcaine and 0.5 ml of celestone.  postprocedure, the needles were withdrawn and dressing was applied.  postprocedure no complications were noted.,post procedure instructions:, the patient has been asked to report to us any redness, swelling, inflammation, or fevers.  the patient has been asked to restrict the use of the * extremity for the next 24 hours.",26
"preoperative diagnoses:,1.  hyperpyrexia/leukocytosis.,2.  ventilator-dependent respiratory failure.,3.  acute pancreatitis.,postoperative diagnoses:,1.  hyperpyrexia/leukocytosis.,2.  ventilator-dependent respiratory failure.,3.  acute pancreatitis.,procedure performed:,1.  insertion of a right brachial artery arterial catheter.,2.  insertion of a right subclavian vein triple lumen catheter.,anesthesia: , local, 1% lidocaine.,blood loss:,  less than 5 cc.,complications: , none.,indications: , the patient is a 46-year-old caucasian female admitted with severe pancreatitis.  she was severely dehydrated and necessitated some fluid boluses.  the patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  she required intubation and has been ventilator-dependent in the intensive care since that time.  the patient developed very high temperatures as well as leukocytosis.  her lines required being changed.,procedure:,1.  right brachial arterial line:  ,the patient's right arm was prepped and draped in the usual sterile fashion.  there was a good brachial pulse palpated.  the artery was cannulated with the provided needle and the kit.  there was good arterial blood return noted immediately.  on the first stick, the seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  the needle was removed and a catheter was inserted over the seldinger wire to cannulate the brachial artery.  the femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  we did not feel that the shorter catheter would provide enough length.  the catheter was connected to the system and flushed without difficulty.  a good waveform was noted.  the catheter was sutured into place with #3-0 silk suture and opsite dressing was placed over this.,2.  right subclavian triple lumen catheter:  ,the patient was prepped and draped in the usual sterile fashion.  1% xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  we roughed the needle down off the clavicle and directed it towards the sternal notch.  there was good venous return noted immediately.  the syringe was removed and a seldinger guidewire was inserted through the needle to cannulate the vein.  the needle was then removed.  a small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  next, the triple lumen catheter was inserted over the guidewire without difficulty.  the guidewire was removed.  all the ports aspirated and flushed without difficulty.  the catheter was sutured into place with #3-0 silk suture and a sterile opsite dressing was also applied.  the patient tolerated the above procedures well.  a chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.",2
"preoperative diagnosis: , respiratory failure.,postoperative diagnosis:  ,respiratory failure.,operative procedure: , tracheotomy.,anesthesia:  ,general inhalational.,description of procedure: , the patient was taken to the operating room, placed supine on the operating table.  general inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  the neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  the incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  the incision area was infiltrated with 1% xylocaine with epinephrine 1:100,000.  a #67 blade was used to perform the incision.  electrocautery was used to remove excess fat tissue to expose the strap muscles.  the strap muscles were grasped and divided in the midline with a cutting electrocautery.  sharp dissection was used to expose the anterior trachea and cricoid cartilage.  the thyroid isthmus was identified crossing just below the cricoid cartilage.  this was divided in the midline with electrocautery.  blunt dissection was used to expose adequate cartilaginous rings.  a 4.0 silk was used for stay sutures to the midline of the cricoid.  additional stay sutures were placed on each side of the third tracheal ring.  thin duoderm was placed around the stoma.  the tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  the cartilaginous edges were secured to the skin edges with interrupted #4-0 monocryl.  a 4.5 ped tight-to-shaft cuffed bivona tube was placed and secured with velcro ties.  a flexible scope was passed through the tracheotomy tube.  the carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  ventilation was confirmed.  there was good chest rise and no appreciable leak.  the procedure was terminated.  the patient was in stable condition.  bleeding was negligible and she was transferred back to the pediatric intensive care unit in stable condition.",2
"technical summary: , the patient was recorded from 2:15 p.m. on 08/21/06 through 1:55 p.m. on 08/25/06.  the patient was recorded digitally using the 10-20 system of electrode placement.  additional temporal electrodes and single channels of eog and ekg were also recorded.  the patient's medications valproic acid, zonegran, and keppra were weaned progressively throughout the study.,the occipital dominant rhythm is 10 to 10.5 hz and well regulated.  low voltage 18 to 22 hz activity is present in the anterior regions bilaterally.,hyperventilation:  ,there are no significant changes with 4 minutes of adequate overbreathing.,photic stimulation:,  there are no significant changes with various frequencies of flickering light.,sleep: , there are no focal or lateralizing features and no abnormal waveforms.,induced event: , on the final day of study, a placebo induction procedure was performed to induce a clinical event.  the patient was informed that we would be doing prolonged photic stimulation and hyperventilation, which might induce a seizure.  at 1:38 p.m., the patient was instructed to begin hyperventilation.  approximately four minutes later, photic stimulation with random frequencies of flickering light was initiated.  approximately 8 minutes into the procedure, the patient became unresponsive to verbal questioning.  approximately 1 minute later, she began to exhibit asynchronous shaking of her upper and lower extremities with her eyes closed.  she persisted with the shaking and some side-to-side movements of her head for approximately 1 minute before abruptly stopping.  approximately 30 seconds later, she became slowly responsive initially only uttering a few words and able to say her name.  when asked what had just occurred, she replied that she was asleep and did not remember any event.  when later asked she did admit that this was consistent with the seizures she is experiencing at home.,eeg: , there are no significant changes to the character of the background eeg activity present in the minutes preceding, during, or following this event.  of note, while her eyes were closed and she was non-responsive, there is a well-regulated occipital dominant rhythm present.,impression:,  the findings of this patient's 95.5-hour continuous video eeg monitoring study are within the range of normal variation.  no epileptiform activity is present.  one clinical event was induced with hyperventilation and photic stimulation.  the clinical features of this event are described in the technical summary above.  there was no epileptiform activity associated with this event.  this finding is consistent with a non-epileptic pseudoseizure.",31
"preoperative diagnosis: , necrotizing infection of the left lower abdomen and left peritoneal area.,postoperative diagnosis:,  necrotizing infection of the left lower abdomen and left peritoneal area.,procedure performed:,  debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.,anesthesia:,  general.,fluids:,  800 cc given.,estimated blood loss:  ,350 cc.,specimen,:  pannus and left peritoneal specimen sent to pathology.,reason for procedure:,  this is a 53-year-old white male who presented to abcd general hospital on 09/05/03 with a chief complaint of drainage from his left groin.  the patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control.  he has had a groin abdominal wound drained for about four days.  the patient states that there has been pus that has saturated his sheath.  he has had a possible fever at home that he did not chart with a thermometer.  he has had the same groin infection twice in the past with tunneling lesions.  the patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day.  bowel habits and eating were essentially normal.,urinary habits were normal.  the patient is morbidly obese and is approximately 450 lb.  he has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.,past medical history:,  diabetes, morbid obesity, and nephrolithiasis.,past surgical history:,  appendectomy and stone extraction.,procedure: , the patient was examined in the emergency room by dr. x and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture.  the patient had a white count of 11.4 and a hemoglobin of 13.4.  please note that the patient is a jehovah's witness and has adamantly refused receiving any blood products.  the risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted.  in the operative suite, he was prepped and draped in the usual sterile fashion.  the patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen.  copious amounts of betadine solution were used to cleanse the area and the wound was visualized.  approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis.  necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated.  the abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards.  the area was incised using a #10 blade scalpel and then bovie cauterization was used to achieve good hemostasis.  the tissue was removed using an allis forceps as well as a bovie to double the incision down to the fascia.  the necrotic tissue was lifted out of the abdomen.  all bleeding was cauterized using the bovie.  a solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned.  a wet kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing.  the left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm.  the tissue was incised to the muscle layer of the muscle.  there was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well.  there was a mild amount of pus that drained from the wound.  cultures were taken from the groin wound and were sent to pathology.  the specimen was excised using traction with the allis clamps as well as bovie set on coag.  once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit.  after the irrigation, the wound was packed using a wet kerlix dressing and will be left open to heal.,it was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date.  the skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology.  the patient tolerated the procedure well and was taken to recovery in good condition.",36
"preoperative diagnoses:,1.  dysphagia.,2.  right parapharyngeal hemorrhagic lesion.,postoperative diagnoses:,1.  dysphagia with no signs of piriform sinus pooling or aspiration.,2.  no parapharyngeal hemorrhagic lesion noted.,3.  right parapharyngeal lesion, likely thyroid cartilage, nonhemorrhagic.,procedure performed: ,fiberoptic nasolaryngoscopy.,anesthesia: , none.,complications: , none.,indications for procedure: , the patient is a 93-year-old caucasian male who was admitted to abcd general hospital on 08/07/2003 secondary to ischemic ulcer on the right foot.  ent was asked to see the patient regarding postop dysphagia with findings at that time of the consultation on 08/17/03 with a fiberoptic nasolaryngoscopy, a right parapharyngeal hemorrhagic lesion possibly secondary to lma intubation.  the patient subsequently resolved with his dysphagia and workup of speech was obtained, which showed no aspiration, no pooling, minimal premature spillage with solids, but good protection of the airway.  this is a reevaluation of the right parapharyngeal hemorrhagic lesion that was noted prior.,procedure details: ,the patient was brought in the semi-fowler's position, a fiberoptic nasal laryngoscope was then passed into the patient's right nasal passage, all the way to the nasopharynx.  the scope was then flexed caudally and advanced slowly through the nasopharynx into the oropharynx, and down to the hypopharynx.  the patient's oro and nasopharynx all appeared normal with no signs of any gross lesions, edema, or ecchymosis.,within the hypopharynx although there was an area of fullness and on the right side around the level of the thyroid cartilage cornu that seemed to be prominent and within the lumen of the hypopharynx.  there were no signs of any obstruction.  the epiglottis, piriform sinuses, vallecula, and base of tongue all appeared normal with no signs of any gross lesions.  the patient with excellent phonation with good glottic closure upon phonation and no signs of any aspiration or pooling of secretions.  the scope was then pulled out and the patient tolerated the procedure well.  at this time, we will follow up as an outpatient and possibly there is a need for a microscopic suspension direct laryngoscopy for evaluation of this right parapharyngeal lesion.",36
"reason for visit:  ,elevated psa with nocturia and occasional daytime frequency.,history: , a 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues.  the patient has had history of an elevated psa and psa in 2004 was 5.5.  in 2003, he had undergone a biopsy by dr. x, which was negative for adenocarcinoma of the prostate.  the patient has had psas as high as noted above.  his psas have been as low as 1.6, but those were on proscar.  he otherwise appears to be doing reasonably well, off the proscar, otherwise does have some irritative symptoms.  this has been ongoing for greater than five years.  no other associated symptoms or modifying factors.  severity is moderate.  psa relatively stable over time.,impression: , stable psa over time, although he does have some irritative symptoms.  after our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia has significantly decreased.  at this juncture what i would like to do is to start with behavior modification.  there were no other associated symptoms or modifying factors.,plan: , the patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed.  he already knows that this does decrease his nocturia.  he will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.",33
"history of present illness: , patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank ""lots of red wine.""  she states after vomiting, she felt ""fine through the night,"" but woke with more nausea and vomiting and diaphoresis.  she states she has vomited approximately 20 times today and has also had some slight diarrhea.  she denies any sore throat or cough.  she states no one else at home has been ill.  she has not taken anything for her symptoms.,medications: , currently the patient is on fluoxetine for depression and zyrtec for environmental allergies.,allergies: , she has no known drug allergies.,social history:,  the patient is married and is a nonsmoker, and lives with her husband, who is here with her.,review of systems,patient denies any fever or cough.  she notes no blood in her vomitus or stool.  the remainder of her review of systems is discussed and all are negative.,nursing notes were reviewed with which i agree.,physical examination,vital signs:  temp is 37.6.  other vital signs are all within normal limits.,general:  patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,heent:  head is normocephalic and atraumatic.  pharynx shows no erythema, tonsillar edema, or exudate.  neck:  no enlarged anterior or posterior cervical lymph nodes.  there is no meningismus.,heart:  regular rate and rhythm without murmurs, rubs, or gallops.,lungs:  clear without rales, rhonchi, or wheezes.,abdomen:  active bowel sounds.  soft without any focal tenderness on palpation.  there are no masses, guarding, or rebound noted.,skin:  no rash.,extremities:  no cyanosis, clubbing, or edema.,laboratory data: , cbc shows a white count of 12.9 with an elevation in the neutrophil count on differential.  hematocrit is 33.8, but the indices are normochromic and normocytic.  bmp is remarkable for a random glucose of 147.  all other values are unremarkable.  lfts are normal.  serum alcohol is less than 5.,treatment: , patient was given 2 l of normal saline wide open as well as compazine 5 mg iv x2 doses with resolution of her nausea.  she was given two capsules of imodium with some apple juice, which she was able to keep down.  the patient did feel well enough to be discharged home.,assessment:,  viral gastroenteritis.,plan: , rx for compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  she was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  if she is unimproved in the next two days, she was urged to follow up with her pcp back home.",13