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history of present illness: ,a 67-year-old male with copd and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath. he was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding copd. unfortunately over the past few months he has returned to pipe smoking. at the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,past medical history: , status post artificial aortic valve implantation in summer of 2002 and is on chronic coumadin therapy. copd as described above, history of hypertension, and history of elevated cholesterol.,physical examination: , heart tones regular with an easily audible mechanical click. breath sounds are greatly diminished with rales and rhonchi over all lung fields.,laboratory studies: ,sodium 139, potassium 4.5, bun 42, and creatinine 1.7. hemoglobin 10.7 and hematocrit 31.7.,hospital course: , he was started on intravenous antibiotics, vigorous respiratory therapy, intravenous solu-medrol. the patient improved on this regimen. chest x-ray did not show any chf. the cortisone was tapered. the patient's oxygenation improved and he was able to be discharged home.,discharge diagnoses: ,chronic obstructive pulmonary disease and acute asthmatic bronchitis.,complications: , none.,discharge condition: , guarded.,discharge plan: , prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge. to follow up with me in the office in 4-5 days.

preoperative diagnosis:, right hallux abductovalgus deformity.,postoperative diagnosis:, right hallux abductovalgus deformity.,procedures performed:,1. right mcbride bunionectomy.,2. right basilar wedge osteotomy with orthopro screw fixation.,anesthesia: , local with iv sedation.,hemostasis: , with pneumatic ankle cuff.,description of procedure: , the patient was brought to the operating room and placed in a supine position. the right foot was prepared and draped in usual sterile manner. anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 marcaine plain infiltrated just proximal to the first metatarsocuneiform joint. hemostasis was achieved utilizing a pneumatic ankle tourniquet placed above the right ankle and inflated to a pressure of 225 mmhg. at this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made. the incision was deepened within the same plain taking care of the bovie and retracted all superficial nerves and vessels as necessary. the incision was then carried down to the underlying capsular structure once again taking care of the bovie and retracted all superficial nerves and vessels as necessary. the capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure. the capsule was then freed from the underling bony structure utilizing sharp and blunt dissection. using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp. at this time, attention was directed to the first inner space using sharp and blunt dissection. dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments. the tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment. at this time, the lateral release was stressed and was found to be complete. the extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection. the entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw. the area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted. at this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length. the incision was deepened within the same plain taking care of bovie and retracted all superficial nerves and vessels as necessary. the incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption. at this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint. at this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge. the osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an orthopro screw 3.0 x 22 mm. the screw was placed following proper technique. the osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing. a very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy. the packing of the cancellous bone was held in place with bone wax. the entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed. at this time, a deep closure was achieved utilizing #2-0 vicryl suture, subcuticular closure was achieved using #4-0 vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion. the hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the mcbride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site. at this time, the surgical site was postoperatively injected with 0.5 marcaine plain as well as dexamethasone 4 mg primarily. the surgical sites were then dressed with sterile xeroform, sterile 4x4s, cascading, and kling with a final protective layer of fiberglass in a nonweightbearing cast fashion. the tourniquet was dropped and color and temperature of all digits returned to normal. the patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,the patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided. the patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,

procedures performed:,1. left heart catheterization.,2. bilateral selective coronary angiography.,3. left ventriculogram was not performed.,indication: , non-st elevation mi.,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. once adequate anesthesia had 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 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 artery was engaged. using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views. once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter. the catheter was then removed over the guidewire.,next, a judkins right #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 manifold and flushed. the catheter did slip into the left ventricle. during the rotation, the lvedp was then measured. the ostium of the right coronary artery was then engaged. using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views. once adequate study has been performed, the catheter was then removed. the sheath was lastly flushed for the final time.,findings:,left main coronary artery: , the left main coronary artery 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 artery: , the lad is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent timi-i flow distally. the distal portion was diffusely diseased. the proximal portion otherwise shows minor luminal irregularities. the first diagonal branch demonstrated minor luminal irregularities throughout.,circumflex artery: ,the circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove. there is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch. the first obtuse marginal branch demonstrates minor luminal irregularities throughout.,right coronary artery: , the rca is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion. the dominant coronary artery gives off the posterior descending artery and posterolateral artery. the left ventricular end-diastolic pressure was approximately 22 mmhg. it should be noted that during injection of the contrast agent that there was st elevation in the inferior leads, which resolved after the injection was complete.,impression:,1. three-vessel coronary artery disease involving a subtotaled left anterior descending artery with timi-i flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2. mildly elevated left-sided filling pressures.,plan:,1. the patient will be transferred to providence hospital today for likely pci of the mid lad lesion with a surgical evaluation for a coronary artery bypass grafting. these findings and plan were discussed in detail with the patient and the patient's family. the patient is agreeable.,2. the patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ace inhibitor, and statin therapy. the patient will not be placed on plavix secondary to the possibility for coronary bypass grafting. in light of the patient's history of cranial aneurysmal bleed, the patient will be held off of lovenox and integrilin.

preoperative diagnosis: , left inguinal hernia.,postoperative diagnosis:, left indirect inguinal hernia.,procedure performed:, repair of left inguinal hernia indirect.,anesthesia: , spinal with local.,complications:, none.,disposition,: the patient tolerated the procedure well, was transferred to recovery in stable condition.,specimen: , hernia sac.,brief history: , the patient is a 60-year-old female that presented to dr. x's office with complaints of a bulge in the left groin. the patient states that she noticed there this bulge and pain for approximately six days prior to arrival. upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,intraoperative findings: , the patient was found to have a left indirect inguinal hernia.,procedure: , after informed consent was obtained, risks and benefits of the procedure were explained to the patient. the patient was brought to the operating suite. after spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion. in the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% marcaine. next, a skin incision was made with a #10 blade scalpel. using bovie electrocautery, dissection was carried down to scarpa's fascia until the external oblique was noted. along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat. next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament. attention was next made to ligating the hernia sac at its base for removal. the hernia sac was opened prior grasping with hemostats. it was a sliding indirect hernia. the bowel contents were returned to abdomen using a #0 vicryl stick tie pursestring suture at its base. the hernia sac was ligated and then cut above with the metzenbaum scissors returning it to the abdomen. this was then sutured at the apex of the repair down to the conjoint tendon. next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 vicryl suture and removed as specimen. attention was next made to reapproximate it at floor with a modified ______ repair. using a #2-0 ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia. once this was done, the external oblique was closed over, reapproximated again with a #2-0 ethibond suture catching each hump in between each repair from the prior floor repair. this was done in simple interrupted fashion as well. next scarpa's fascia was reapproximated with #3-0 vicryl suture. the skin was closed with running subcuticular #4-0 undyed vicryl suture. steri-strips and sterile dressings were applied. the patient tolerated the procedure very well and he was transferred to recovery in stable condition. the patient had an abnormal chest x-ray in preop and is going for a ct of the chest in recovery.

preoperative diagnosis:, right renal mass.,postop diagnosis: , right renal mass.,procedure performed:, laparoscopic right radical nephrectomy.,estimated blood loss:, 100 ml.,x-rays: , none.,specimens: , right radical nephrectomy specimen.,complications: , none.,anesthesia: ,general endotracheal.,drains:, 16-french foley catheter per urethra.,brief history: , the patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass. this is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma. i discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy. all questions were answered, and she wished to proceed with surgery as planned.,procedure in detail:, after acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table. note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia. after institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest. all pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure. her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-french foley catheter per urethra to gravity drainage. the abdomen was insufflated in the right outer quadrant. note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy. the abdomen was insufflated into the right lateral abdomen with veress needle to 50 mm of pressure without incident. we then placed a 10/12 visiport trocar approximately 7 cm lateral to the umbilicus. once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed. under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar. there were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,we began nephrectomy procedure by reflecting the right colon, by incising the white line of toldt. this exposed the retroperitoneum on the right side. the duodenum was identified and reflected medially in a kocher maneuver using sharp dissection only. we then identified the ureter and gonadal vein in the retroperitoneum. the gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum. sequential packets of tissue were taken using primarily the ligasure atlas device. once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins. we proceeded then and skeletonized the structures into four individual packets. we then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland. the adrenal was spared during this procedure. there was no contiguous connection between the renal mass and a right adrenal gland. this plane of dissection was taken down primarily using the ligasure device. we then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo gi stapler and then to renal veins again with endo gi stapler sequential flaring. once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments. the lateral attachments of the kidney were taken down using the ligasure atlas device, and then the ureter was doubly clipped and transected. the kidney was then freed within the retroperitoneum. a 50-mm endocatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction. we extended the lower most trocar site approximately 6 cm to facilitate extraction. the kidney was removed and passed off the table as a specimen for pathology. this was bivalved by pathology, and we reviewed the specimen.

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.

procedure: , medial branch rhizotomy, lumbosacral.,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.,sedation: , the patient was given conscious sedation and monitored throughout the procedure. oxygenation was given. the patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,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 with a pillow under the abdomen to reduce the natural lumbar lordosis. 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 boney landmarks of the spine and the planned needle approach. the skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% lidocaine. with fluoroscopy, a teflon coated needle, ***, was gently guided into the region of the medial branch nerves from the dorsal ramus of ***. specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen. needle localization was confirmed with ap and lateral radiographs.,the following technique was used to confirm placement at the medial branch nerves. sensory stimulation was applied to each level at 50 hz; paresthesias were noted at,*** volts. motor stimulation was applied at 2 hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** 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, 1cc 1% lidocaine was injected to anesthetize the medial branch nerve and surrounding tissue. after completion of each nerve block a lesion was created at that level with a temperature of 85 degrees celsius for 90 seconds. all injected medications were preservative free. sterile technique was used throughout the procedure.,complications:, none. no complications.,the patient tolerated the procedure well and was sent to the recovery room in good condition.,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 in approximately 1 week.

exam: , ct abdomen without contrast and pelvis without contrast, reconstruction.,reason for exam: , right lower quadrant pain, rule out appendicitis.,technique: ,noncontrast ct abdomen and pelvis. an intravenous line could not be obtained for the use of intravenous contrast material.,findings: , the appendix is normal. there is a moderate amount of stool throughout the colon. there is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. examination of the extreme lung bases appear clear, no pleural effusions. the visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. there is a small hiatal hernia. there is no intrarenal stone or evidence of obstruction bilaterally. there is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. this can be correlated with a followup ultrasound if necessary. the gallbladder has been resected. there is no abdominal free fluid or pathologic adenopathy. there is abdominal atherosclerosis without evidence of an aneurysm.,dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. there are surgical clips present. there is a tiny airdrop within the bladder. if this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,impression:,1.normal appendix.,2.moderate stool throughout the colon.,3.no intrarenal stones.,4.tiny airdrop within the bladder. if this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. the report was faxed upon dictation.

preoperative diagnosis:, carpal tunnel syndrome.,postoperative diagnosis: , carpal tunnel syndrome.,title of procedure: , endoscopic carpal tunnel release.,anesthesia: , mac,procedure: , 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.,i made a transverse incision one fingerbreadth proximal to the distal volar wrist crease. dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion. bipolar electrocautery was used to maintain meticulous hemostasis. i then performed an antebrachial fasciotomy proximally. i entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area. great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side. great care was taken with placement. a good plane was positively identified. i then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,again, i felt the hook of the hamate ulnar to me. i had my thumb on the distal aspect of the transverse carpal ligament. i then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified. i pulled back and cut and partially tightened the transverse carpal ligament. i then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament. i then checked to make sure this was properly performed and then cut the proximal aspect. i then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, i could see only one in the field at a time. great care was taken and at no point was there any longitudinal structure cut. under direct vision through the incision, i made sure that the distal antebrachial fascia was cut. following this, i irrigated and closed the skin. the patient was dressed and sent to the recovery room in good condition.

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.

indications for procedure:, persistent cough productive of sputum requiring repeated courses of oral antibiotics over the last six weeks in a patient who is a recipient of a bone marrow transplant with end-stage chemotherapy and radiation-induced pulmonary fibrosis.,premedication:,1. demerol 50 mg.,2. phenergan 25 mg.,3. atropine 0.6 mg im.,4. nebulized 4% lidocaine followed by nasal insufflation of lidocaine through the right naris and topical 4% lidocaine gel through the right naris, 4 mg of versed was given at the start of the procedure and another 1 mg shortly after traversing the cords.,procedure details:, with the patient breathing oxygen by nasal cannula, being monitored by noninvasive blood pressure cuff and continuous pulse oximetry, the olympus bronchoscope was introduced through the right naris to the level of the cords. the cords move normally with phonation and ventilation. two times 2 ml of 1% lidocaine were instilled on the cords and the cords were traversed. further 2 ml of 1% lidocaine was instilled in the trachea just distal to the cords, at mid trachea above the carina, and on the right, and on the left mainstem bronchus. scope was then introduced on to the left where immediately some hyperemia of the mucosa was noted. upper lobe and lingula were unremarkable. there appeared to be some narrowing or tenting of the left lower lobe bronchus such that after inspection of the superior segment, one almost had to pop the bronchoscope around to go down the left mainstem. this had been a change from the prior bronchoscopy of unclear significance. distal to this, there was no hyperemia or inspissated mucus or mucoid secretions or signs of infection. the scope was wedged in the left lower lobe posterior basal segment and a bal was done with good returns, which were faintly hemorrhagic. the scope was then removed, re-introduced up to the right upper lobe, middle lobe, superior segment, right lower, anterior lateral, and posterior basal subsegments were all evaluated and unremarkable. the scope was withdrawn. the patient's saturation remained 93%-95% throughout the procedure. blood pressure was 103/62. heart rate at the end of the procedure was about 100. the patient tolerated the procedure well. samples were sent as follows. washings for afb, gram-stain nocardia, aspergillus, and routine culture. lavage for afb, gram-stain nocardia, aspergillus, cell count with differential, cytology, viral mycoplasma, and chlamydia culture, gms staining, rsv by antigen, and legionella and chlamydia culture.

subjective:, this is an 18-year-old white female who presents for complete physical, pap, and breast exam and to have paperwork filled out for college. she denies any problems at this time. her last pap smear was 06/25/2003 and was normal. she is requesting to switch from ortho-tri-cyclen to seasonale at this time. we did discuss that she may have increased episodes of breakthrough bleeding.,past medical history:, fever blisters and allergic rhinitis.,medications: , allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and ortho-tri-cyclen.,allergies:, none.,social history:, denies tobacco or drug use, rare alcohol use. she is sexually active and has had one partner.,family history: ,positive for rheumatoid arthritis.,review of systems:, heent, pulmonary, cardiovascular, gi, gu, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for hpi.,objective:,vital signs: height 5 feet 6 inches. weight 153 pounds. blood pressure 106/72. pulse 68. respirations 12. temperature 97.5. last menstrual period 05/30/2004.,general: she is a well-developed, well-nourished white female in no acute distress.,heent: tympanic membranes unremarkable. oropharynx nonerythematous. pupils equal, round, and reactive to light. extraocular muscles intact.,neck: supple. no lymphadenopathy and no thyromegaly.,chest: clear to auscultation bilaterally.,cv: regular rate and rhythm without murmur.,abdomen: positive bowel sounds. soft and nontender. no hepatosplenomegaly.,breasts: no nipple discharge. no lumps or masses palpated. no dimpling of the skin. no axillary lymph nodes palpated. self-breast exam discussed and encouraged.,pelvic: normal female genitalia. normal vaginal rugation. no cervical lesions. no cervical motion tenderness. no adnexal tenderness or masses palpated.,extremities: no cyanosis, clubbing, or edema.,neurologic: 2+/4 dtrs in all extremities. 5/5 motor strength in all extremities. negative romberg.,musculoskeletal: no abnormalities or laxity noted in any of her joints.,assessment/plan:,1. complete physical, pap, and breast exam completed.,2. school physical form completed and returned to the patient.,3. hepatitis b second injection will be given today.,4. contraceptive surveillance. we will put patient to seasonale to start at the end of this cycle a pill.,5. allergic rhinitis. prescription was given for allegra 180 mg q.d. #30 carrying refills for her to take with her school cowley county community college.,6. insomnia. prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school. she will follow up as needed.

preoperative diagnosis: , cervical lymphadenopathy.,postoperative diagnosis:, cervical lymphadenopathy.,procedure: , excisional biopsy of right cervical lymph node.,anesthesia: , general endotracheal anesthesia.,specimen: , right cervical lymph node.,ebl: , 10 cc.,complications: , none.,findings:, enlarged level 2 lymph node was identified and removed and sent for pathologic examination.,fluids: , please see anesthesia report.,urine output: , none recorded during the case.,indications for procedure: , this is a 43-year-old female with a several-year history of persistent cervical lymphadenopathy. she reports that it is painful to palpation on the right and has had multiple ct scans as well as an fna which were all nondiagnostic. after risks and benefits of surgery were discussed with the patient, an informed consent was obtained. she was scheduled for an excisional biopsy of the right cervical lymph node.,procedure in detail: , the patient was taken to the operating room and placed in the supine position. she was anesthetized with general endotracheal anesthesia. the neck was then prepped and draped in the sterile fashion. again, noted on palpation there was an enlarged level 2 cervical lymph node.,a 3-cm horizontal incision was made over this lymph node. dissection was carried down until the sternocleidomastoid muscle was identified. the enlarged lymph node that measured approximately 2 cm in diameter was identified and was removed and sent to pathology for touch prep evaluation. the area was then explored for any other enlarged lymph nodes. none were identified, and hemostasis was achieved with electrocautery. a quarter-inch penrose drain was placed in the wound.,the wound was then irrigated and closed with 3-0 interrupted vicryl sutures for a deep closure followed by a running 4-0 prolene subcuticular suture. mastisol and steri-strip were placed over the incision, and sterile bandage was applied. the patient tolerated this procedure well and was extubated without complications and transported to the recovery room in stable condition. she will return to the office tomorrow in followup to have the penrose drain removed.

exam:,mri left knee without contrast,clinical:,left knee pain.,findings:,comparison is made with 10/13/05 radiographs.,there is a prominent suprapatellar effusion. patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. there is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. no tear is seen. anterior cruciate and posterior cruciate ligaments are intact. there is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. there is suggestion of some mild posterior aspect of the lateral tibial plateau. mr signal on the bone marrow is otherwise normal.,impression:,type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.

history of present illness: ,this is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. at the time of my exam, he states that his left lower extremity pain has improved considerably. he apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. he does have a history of multiple medical problems including atrial fibrillation, he is on coumadin, which is currently subtherapeutic, multiple cvas in the past, peripheral vascular disease, and congestive heart failure. he has multiple chronic history of previous ischemia of his large bowel in the past.,physical exam,vital signs: currently his temperature is 98.2, pulse is 95, and blood pressure is 138/98.,heent: unremarkable.,lungs: clear.,cardiovascular: an irregular rhythm.,abdomen: soft.,extremities: his upper extremities are well perfused. he has palpable radial and femoral pulses. he does not have any palpable pedal pulses in either right or left lower extremity. he does have reasonable capillary refill in both feet. he has about one second capillary refill on both the right hand and left lower extremities and his left foot is perhaps little cool, but it is relatively warm. apparently, this was lot worst few hours ago. he describes significant pain and pallor, which he feels has improved and certainly clinically at this point does not appear to be as significant.,impression and plan: , this gentleman with a history of multiple comorbidities as detailed above had what sounds clinically like acute exacerbation of chronic peripheral vascular disease, essentially related to spasm versus a small clot, which may have been lysed to some extent. he currently has a viable extremity and viable foot, but certainly has significant making compromised flow. it is unclear to me whether this is chronic or acute, and whether he is a candidate for any type of intervention. he certainly would benefit from an angiogram to better to define his anatomy and anticoagulation in the meantime. given his potential history of recent lower gi bleeding, he has been evaluated by gi to see whether or not he is a candidate for heparinization. we will order an angiogram for the next few hours and followup on those results to better define his anatomy and to determine whether or not if any interventions are appropriate. again, at this point, he has no pain, relatively rapid capillary refill, and relatively normal motor function suggesting a viable extremity. we will follow him along closely.

cc:, left third digit numbness and wrist pain.,hx: ,this 44 y/o lhm presented with a one month history of numbness and pain of the left middle finger and wrist. the numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. within a few days he developed pain in his wrist. he had been working as a cook and cut fish for prolonged periods of time. this activity exacerbated his symptoms. he denied any bowel/bladder difficulties, neck pain, or weakness. he had no history of neck injury.,shx/fhx:, 1-2 ppd cigarettes. married. off work for two weeks due to complaints.,exam: ,vital signs unremarkable.,ms:, a & o to person, place, time. fluent speech without dysarthria.,cn ii-xii: ,unremarkable,motor:, 5/5 throughout, including intrinsic muscles of hands. no atrophy or abnormal muscle tone.,sensory:, decreased pp in third digit of left hand only (palmar and dorsal sides).,station/gait/coord:, unremarkable.,reflexes: ,1+ throughout, plantar responses were downgoing bilaterally.,gen exam: ,unremarkable.,tinel's manuever elicited pain and numbness on the left. phalens sign present on the left.,clinical impression: ,left carpal tunnel syndrome,emg/ncv: ,unremarkable.,mri c-spine, 12/1/92: congenitally small spinal canal is present. superimposed on this is mild spondylosis and disc bulge at c6-7, c5-6, c4-5, and c3-4. there is moderate central spinal stenosis at c3-4. intervertebral foramina at these levels appear widely patent.,course:, the mri findings did not correlate with the clinical findings and history. the patient was placed on elavil and was subsequently lost to follow-up.

preoperative diagnoses: ,1. nasolabial mesiolabial fold.,2. mid glabellar fold.,postoperative diagnoses: ,1. nasolabial mesiolabial fold.,2. mid glabellar fold.,title of procedures: ,1. perlane injection for the nasolabial fold.,2. restylane injection for the glabellar fold.,anesthesia: ,topical with lasercaine.,complications: , none.,procedure: , the patient was evaluated preop and noted to be in stable condition. chart and informed consent were all reviewed preop. all risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. this includes risk of bleeding, infection, scarring, need for further procedure, etc. the patient did sign the informed consent form regarding the perlane and restylane. she is aware of the potential risk of bruising. the patient has had cosmederm in the past and had had a minimal response with this. please note lasercaine had to be applied 30 minutes prior to the procedure. the excess lasercaine was removed with a sterile alcohol swab.,using the linear threading technique, i injected the deep nasolabial fold. we used 2 ml of the perlane for injection of the nasolabial mesiolabial fold. they were carefully massaged into good position at the end of the procedure. she did have some mild erythema noted.,i then used approximately 0.4 ml of the restylane for injection of the mid glabellar site. she has a resting line of the mid glabella that did not respond with previous botox injection. once this was filled, the restylane was massaged into the proper tissue plane. cold compressors were applied afterwards. she is scheduled for a recheck in the next one to two weeks, and we will make further recommendations at that time. post restylane and perlane precautions have been reviewed with the patient as well.

chief complaint: , left knee pain and stiffness.,history of present illness: , the patient is a 57-year-old with severe bilateral knee djd, left greater than right, with significant pain and limitations because of both. he is able to walk approximately a 1/2-mile a day but is limited because of his knees. stairs are negotiated 1 at a time. his problems with bilateral knee djd have been well documented. he had arthroscopy in the 1991/199two time frame for both of these. he has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. at this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. he does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. significant pain is handled by narcotic medication. his attending physician is dr. x.,past medical history: , hypertension.,prior surgeries:,1. inguinal hernia on the left.,2. baker's cyst.,3. colon cancer removal.,4. bilateral knee scopes.,5. right groin hernia.,6. low back surgery for spinal stenosis.,7. status post colon cancer second surgery.,medications:,1. ambien 12.5 mg nightly.,2. methadone 10 mg b.i.d.,3. lisinopril 10 mg daily.,iv medications for pain: ,demerol appears to work the best.,allergies: , levaquin and cipro cause rashes; ibuprofen causes his throat to swell, fortaz causes an unknown reaction.,review of systems: ,he does have paresthesias down into his thighs secondary to spinal stenosis.,social history: , married. he is retired, being a pepsi-cola driver secondary to his back and knees.,habits: , no tobacco or alcohol. chewed until 2003.,recreational pursuits: ,golfs, gardens, woodworks.,family history:,1. cancer.,2. coronary artery disease.,physical examination:,general appearance: a pleasant, cooperative 57-year-old white male.,vital signs: height 5' 9", weight 167. blood pressure 148/86. pulse 78 per minute and regular.,heent: unremarkable. extraocular movements are full. cranial nerves ii-xii intact.,neck: supple.,chest: clear.,cardiovascular: regular rhythm. normal s1 and 2.,abdomen: no organomegaly. no tenderness. normal bowel sounds.,neurologic: intact.,musculoskeletal: left knee reveals a range of -10 degrees extension, 126 flexion. his extensor mechanism is intact. there is mild varus. he has good stability at 30 degrees of flexion. lachman's and posterior drawer are negative. he has good muscle turgor. dorsalis pedis pulse 2+.,diagnostics: ,x-rays revealed severe bilateral knee djd with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,impression:,1. bilateral knee degenerative joint disease.,2. significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.

clinical history:, gravida 1, para 0 at 33 weeks 5 days by early dating. the patient is developing gestational diabetes.,transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation. the placenta was posterior in position. there was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,the following measurements were obtained: biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm. these values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,conclusion:, normal biophysical profile (bpp) with a score of 8 out of possible 8. the fetus is size appropriate for gestation.

reason for visit:, followup on chronic kidney disease.,history of present illness:, the patient is a 78-year-old gentleman with stage iii chronic kidney disease who on his last visit with me presented with classic anginal symptoms. he was admitted to hospital and found to have an acute myocardial infarction. he had a complex hospital course, which resulted in cardiac catheterization and two stents being placed. his creatinine did pop above up to 3 but then came back to baseline. his hospital stay was also complicated by urinary retention requiring a catheter and flomax. he returns today to re-establish care. of note, he was noted to have atrial fibrillation while hospitalized and had massive epistaxis.,allergies:, none.,medications: , starlix 120 mg b.i.d., compazine b.i.d., aspirin 81 mg daily, plavix 75 mg daily, glipizide 15 mg b.i.d., multivitamin daily, potassium 10 meq daily, cozaar 25 mg daily, prilosec 20 mg daily, digoxin 0.125 mg every other day, vitamin c 250 mg daily, ferrous sulphate 325 mg b.i.d., metoprolol 6.25 mg daily, lasix 80 mg b.i.d., flomax 0.4 mg daily, zocor 80 mg daily, and tylenol p.r.n.,past medical history:,1. stage iii ckd with baseline creatinine in the 2 range.,2. status post mi on may 30, 2006.,3. coronary artery disease status post stents of the circumflex.,4. congestive heart failure.,5. atrial fibrillation.,6. copd.,7. diabetes.,8. anemia.,9. massive epistaxis.,review of systems:, cardiovascular: no chest pain. he has occasional dyspnea on exertion. no orthopnea. no pnd. he has occasional edema of his right leg. he has been dizzy and his dose of metoprolol has been gradually decreased. gu: no hematuria, foamy urine, pyuria, frequency, dysuria, weak stream or dribbling.,physical examination: , vital signs: pulse 70. blood pressure 114/58. weight 79.5 kg. general: he is in no apparent distress. heart: irregularly irregular. no murmurs, rubs, or gallops. lungs: clear bilaterally. abdomen: soft, nontender, and nondistended. extremities: trace edema on the right.,laboratory data: , dated 07/05/06, hematocrit is 30.2, platelets 380, sodium 139, potassium 4.9, chloride 100, co2 28, bun 38, creatinine 2.2, glucose 226, calcium 9.7, and albumin 3.7.,impression:,1. stage iii chronic kidney disease with return to baseline gfr of 31 ml/min. he is on an arb.,2. coronary artery disease, status post stenting.,3. hypertension. blood pressures are on the low side at present. i hesitate to increase his cozaar although i would do this if tolerated in the future.,4. anemia of renal disease. he is to start aranesp.,5. ? atrial fibrillation. we discussed anticoagulation issues involved with chronic afib. he may be popping in and out or this could just be a sinus arrhythmia.,plan:,1. check ekg.,2. start aranesp 60 mcg every two weeks.,3. otherwise see him in four months.,4. if ekg shows atrial fibrillation, i wanted to talk to dr. xyz about coumadin.

preoperative diagnosis: , mesothelioma.,postoperative diagnosis:, mesothelioma.,operative procedure: , placement of port-a-cath, left subclavian vein with fluoroscopy.,assistant:, none.,anesthesia: , general endotracheal.,complications:, none.,description of procedure: , the patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma. he was brought to the operating room now for port-a-cath placement for chemotherapy. after informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position. after induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted. needle was removed. small incision was made large enough to harbor the port. dilator and introducers were then placed over the guidewire. guidewire and dilator were removed, and a port-a-cath was introduced in the subclavian vein through the introducers. introducers were peeled away without difficulty. he measured with fluoroscopy and cut to the appropriate length. the tip of the catheter was noted to be at the junction of the superior vena cava and right atrium. it was then connected to the hub of the port. port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall. wounds were then closed. needle count, sponge count, and instrument counts were all correct.

preoperative diagnoses: , progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,postoperative diagnoses:, progressive exertional angina, three-vessel coronary artery disease, left main disease, preserved left ventricular function.,operative procedure: , coronary artery bypass grafting (cabg) x4.,grafts performed: , lima to lad, left radial artery from the aorta to the pda, left saphenous vein graft from the aorta sequential to the diagonal to the obtuse marginal.,indications for procedure: , the patient is a 74-year-old gentleman, who presented with six-month history of progressively worsening exertional angina. he had a positive stress test and cardiac cath showed severe triple-vessel coronary artery disease including left main disease with preserved lv function. he was advised surgical revascularization of his coronaries.,findings during the procedure: ,the aorta was free of any significant plaque in the ascending portion at the sites of cannulation and cross clamp. left internal mammary artery and saphenous vein grafts were good quality conduits. radial artery graft was a smaller sized conduit, otherwise good quality. all distal targets showed heavy plaque involvement with calcification present. the smallest target was the pda, which was about 1.5 mm in size. all the other targets were about 2 mm in size or greater. the patient came off cardiopulmonary bypass without any problems. he was transferred on neo-synephrine, nitroglycerin, precedex drips. cross clamp time was 102 minutes, bypass time was 120 minutes.,details of the procedure: ,the patient was brought into the operating room and laid supine on the table. after he had been interfaced with the appropriate monitors, general endotracheal anesthesia was induced and invasive monitoring lines including right ij triple-lumen catheter and cordis catheter, right radial a-line, foley catheter, tee probes were placed and interfaced appropriately. the patient was then prepped and draped from chin to bilateral ankles including the left forearm in the usual sterile fashion. preoperative checkup of the left forearm has revealed good collateral filling from the ulnar with the radial occluded thus indicating good common arch and thus left radial artery was suitable for harvest.,after prepping and draping the patient from the chin to bilateral ankles including left forearm in the usual sterile fashion, proper time-out was conducted and site identification was performed, and subsequently incision was made overlying the sternum and median sternotomy was performed. left internal mammary artery was taken down. simultaneously, left forearm radial artery was harvested using endoscopic harvesting techniques. simultaneously, endoscopic left leg saphenous vein was harvested using endoscopic minimally invasive techniques. subsequent to harvest, the incisions were closed in layers during the course of the procedure.,heparin was given. pericardium was opened and suspended. during the takedown of the left internal mammary artery, it was noted that the left pleural space was globally softened and left lung was adherent to the chest wall and mediastinum globally. only a limited dissection was performed to free up the lung from the mediastinal structures to accommodate the left internal mammary artery.,pericardium was opened and suspended. pursestring sutures were placed. aortic and venous as well as antegrade and retrograde cardioplegia cannulation was performed and the patient was placed on cardiopulmonary bypass. with satisfactory flow, the aorta was cross clamped and the heart was arrested using a combination of antegrade and retrograde cold blood cardioplegia. an initial dose of about 1500 ml was given and this was followed by intermittent doses given both antegrade and retrograde throughout the procedure to maintain a good arrest and to protect the heart.,pda was exposed first. the right coronary artery was calcified along its course all the way to its terminal bifurcation. even in the pda, calcification was noted in a spotty fashion. arteriotomy on the pda was performed in a soft area and 1.5 probe was noted to be accommodated in both directions. end radial to side pda anastomosis was constructed using running 7-0 prolene. next, the posterolateral obtuse marginal was exposed. arteriotomy was performed. an end saphenous vein to side obtuse marginal anastomosis was constructed using running 7-0 prolene. this graft was then apposed to the diagonal and corresponding arteriotomy and venotomies were performed and a diamond shaped side-to-side anastomosis was constructed using running 7-0 prolene. next, a slit was made in the left side of the pericardium and lima was accommodated in the slit on its way to the lad. lad was exposed. arteriotomy was performed. an end lima to side lad anastomosis was constructed using running 7-0 prolene. lima was tacked down to the epicardium securely utilizing its fascial pedicle.,two stab incisions were made in the ascending aorta and enlarged using 4-mm punch. two proximal anastomosis were constructed between the proximal end of the saphenous vein graft and the side of the aorta, and the proximal end of the radial artery graft and the side of the aorta separately using running 6-0 prolene. the patient was given terminal dose of warm retrograde followed by antegrade cardioplegia during which de-airing maneuvers were performed. following this, the aortic cross clamp was removed and the heart was noted to resume spontaneous coordinated contractile activity. temporary v-pacing wires were placed. blake drains were placed in the left chest, the right chest, as well as in the mediastinum. left chest blake drain was placed just in the medial section where dissection had been performed. after an adequate period of rewarming during which time, temporary v-pacing wires were also placed, the patient was successfully weaned off cardiopulmonary bypass without any problems. with satisfactory hemodynamics, good lv function on tee and baseline ekg, heparin was reversed using protamine. decannulation was performed after volume resuscitation. hemostasis was assured. mediastinal and pericardial fat and pericardium were loosely reapproximated in the midline and chest was closed in layers using interrupted stainless steel wires to reappose the two sternal halves, heavy vicryl for musculofascial closure, and monocryl for subcuticular skin closure. dressings were applied. the patient was transferred to the icu in stable condition. he tolerated the procedure well. all counts were correct at the termination of the procedure. cross clamp time was 102 minutes. bypass time was 120 minutes. the patient was transferred on neo-synephrine, nitroglycerin, and precedex drips.

history of present illness:, this is a 10-year-old who was found with biliary atresia and underwent a kasai procedure and did not really well because she ended up having a liver transplant. the patient did well after the liver transplant and the only problems started:,1. history of food allergies.,2. history of dental cavities.,at this time, the patient came for a followup and is complaining of a left upper molar pain. there are no other complaints.,diet: , lactose-limited diet.,medications: , please see the mrc form.,allergies: , there are no allergies.,social history:, the patient lives with the parents in lindsay, california and has a good environment.,family history: , negative for gastrointestinal illness except that a sibling has ulcerative colitis.,review of systems: , the system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,physical examination: ,measurements: height 135 cm and weight 28.1 kg.,vital signs: temperature 98.9 and blood pressure 105/57.,general: a well-developed, well-nourished child in no acute distress.,heent: atraumatic and normocephalic. the pupils are equal, round, and reactive to light. full eoms. the conjunctivae and sclerae are clear. the tms show normal landmarks. the nasal mucosa is pink and moist. the teeth and gums are in good condition. the pharynx is clear.,neck: supple, without thyromegaly and without masses.,lymphatic: no adenopathy.,lungs: clear to auscultation, with no retractions.,coronary: regular rhythm without murmur. s1 and s2 are normal. the pulses are full and symmetrical bilaterally.,abdomen: normal bowel sounds. no hepatosplenomegaly, no masses, and no tenderness.,genitalia: normal female by inspection.,skin: no unusual lesions.,back: no scoliosis, hairy patch, lipoma, or sacral dimple.,extremities: no cyanosis, clubbing, or edema.,central nervous system: developmentally appropriate for age. dtrs are 2+ and symmetrical. the toes are downgoing bilaterally. motor and sensory without asymmetry. cranial nerves ii through xii are grossly intact.,laboratory data:, laboratory data from 12/30/2007 tacrolimus 3.1 and negative epstein-barr, cmv was not detected.,final impression:, this is a 10-year-old with history of:,1. biliary atresia.,2. status post orthotopic liver transplantation.,3. dental cavities.,4. food allergies.,5. history of urinary tract infections.,plan: , our plan would be to continue with the medications as follows:,1. prograf 0.5 mg p.o. b.i.d.,2. valganciclovir 420 mg p.o. b.i.d.,3. labs every 2 to 3 months.,4. to return to clinic in 4 months.,5. to refer this patient to a pediatric dentist for assessment of the dental cavities.

procedure:, punch biopsy of right upper chest skin lesion.,estimated blood loss:, minimal.,fluids: , minimal.,complications:, none.,procedure:, the area around the lesion was anesthetized after she gave consent for her procedure. punch biopsy including some portion of lesion and normal tissue was performed. hemostasis was completed with pressure holding. the biopsy site was approximated with non-dissolvable suture. the area was hemostatic. all counts were correct and there were no complications. the patient tolerated the procedure well. she will see us back in approximately five days.,

preoperative diagnosis: , epistaxis and chronic dysphonia.,postoperative diagnoses:,1. atrophic dry nasal mucosa.,2. epistaxis.,3. atrophic laryngeal changes secondary to inhaled steroid use.,procedure performed:,1. cauterization of epistaxis, left nasal septum.,2. fiberoptic nasal laryngoscopy.,anesthesia: , neo-synephrine with lidocaine nasal spray.,findings:,1. atrophic dry cracked nasal mucosa.,2. atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,indications: , the patient is a 37-year-old african-american female who was admitted to abcd general hospital with a left wrist abscess. the patient was taken to the operating room for incision and drainage. postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis. upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery. the patient does report of having endotracheal tube intubation during anesthesia. the patient also gives a history of inhaled steroid use for her asthma.,the patient was extubated after surgery without difficulty, but continued to have some difficulty and the department of otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,procedure details:, after the procedure was described, the patient was placed in the seated position. the fiberoptic nasal laryngoscope was then inserted into the patient's left naris. the nasal mucosal membranes were dry and atrophic throughout. there was no evidence of any mass lesions. the nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity. there was no evidence of mass, ulceration, lesion, or obstruction. the nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,the fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes. there was no evidence of any local mass lesion, nodule, or ulcerations. there was no evidence of any erythema. upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric. the airway was stable and patent throughout the entire examination. the nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx. the eustachian tube was completely visualized and was patent without obstruction. the scope was then further removed without difficulty. the patient tolerated the procedure well and remained in stable condition.,recommendations and plan: , the patient would benefit from ocean nasal spray as well as bacitracin ointment applied to the anterior naris. at this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma. if this becomes possible in the future, this may provide her some relief of her chronic dysphonia. the patient is to follow up with department of otolaryngology after discharge from the hospital for further evaluation of these problems.

diagnoses problems:,1. orthostatic hypotension.,2. bradycardia.,3. diabetes.,4. status post renal transplant secondary polycystic kidney disease in 1995.,5. hypertension.,6. history of basal cell ganglia cerebrovascular event in 2004 with left residual.,7. history of renal osteodystrophy.,8. iron deficiency anemia.,9. cataract status post cataract surgery.,10. chronic left lower extremity pain.,11. hyperlipidemia.,12. status post hysterectomy secondary to uterine fibroids.,procedures:, telemetry monitoring.,history findings hospital course: , the patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. she was transferred briefly to psychiatry, however, on the second day in psychiatry, she became very orthostatic and was transferred acutely back to the medicine. she briefly was on cymbalta; however, this was discontinued when she was transferred back. she was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. she was able to maintain her pressures then was able to ambulate without difficulty. we had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,discharge medications:,1. cellcept - 500 mg twice a daily.,2. cyclosporine - 25 mg in the morning and 15 mg in the evening.,3. prednisone - 5 mg once daily.,4. hydralazine - 10 mg four times a day.,5. pantoprazole - 40 mg once daily.,6. glipizide - 5 mg every morning.,7. aspirin - 81 mg once daily.,followup care: ,the patient is to follow up with dr. x in about 1 week's time.

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.

general: , a well-developed infant in no acute respiratory distress.,vital signs: ,initial temperature was xx, pulse xx, respirations xx. weight xx grams, length xx cm, head circumference xx cm.,heent: ,head is normocephalic with anterior fontanelle open, soft, and non-bulging. eyes: red reflex elicited bilaterally. tms occluded with vernix and not well visualized. nose and throat are patent without palatal defect.,neck: , supple without clavicular fracture.,lungs:, clear to auscultation.,heart:, regular rate without murmur, click, or gallop present. pulses are 2/4 for brachial and femoral.,abdomen:, soft with bowel sounds present. no masses or organomegaly.,genitalia: , normal.,extremities: , without evidence of hip defects.,neurologic: ,the infant has good moro, grasp, and suck reflexes.,skin: , warm and dry without evidence of rash.

exam:, nuclear medicine tumor localization, whole body.,history: , status post subtotal thyroidectomy for thyroid carcinoma, histology not provided.,findings: , following the oral administration of 4.3 mci iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours.,there is increased uptake in the left upper quadrant, which persists throughout the examination. there is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours. physiologic uptake in the liver, spleen, and transverse colon is noted. physiologic urinary bladder uptake is also appreciated. there is low-grade uptake in the oropharyngeal region.,impression: ,iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis. anatomical evaluation, i.e., ct is advised to determine if there are corresponding mesenteric lesions. ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) pet scanning may be necessary. no evidence of iodine added locoregional metastasis.

procedure: , circumcision.,signed informed consent was obtained and the procedure explained.,the child was placed in a circumstraint board and restrained in the usual fashion. the area of the penis and scrotum were prepared with povidone iodine solution. the area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure. a dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine. a dorsal slit was made, and the prepuce was dissected away from the glans penis. a ** gomco clamp was properly placed for 5 minutes. during this time, the foreskin was sharply excised using a #10 blade. with removal of the clamp, there was a good cosmetic outcome and no bleeding. the child appeared to tolerate the procedure well. care instructions were given to the parents.

preoperative diagnosis: ,prostate cancer.,postoperative diagnosis:, prostate cancer.,operation performed:, radical retropubic nerve-sparing prostatectomy without lymph node dissection.,estimated blood loss: , 450 ml.,replacement:, 250 ml of cell saver and crystalloid.,complications: , none.,indications of surgery: , this is a 67-year-old man with needle biopsy proven to be gleason 6 adenocarcinoma in one solitary place on the right side of the prostate. due to him being healthy with no comorbid conditions, he has elected to undergo surgical treatment with radical retropubic prostatectomy. potential complications include, but are not limited to:,1. infection.,2. bleeding.,3. incontinence.,4. impotence.,5. injury to the adjacent viscera.,6. deep venous thrombosis.,procedure in detail: , prophylactic antibiotic was given in the preoperative holding area, after which the patient was transferred to the operating room. epidural anesthesia and general endotracheal anesthesia were administered by dr. a without any difficulty. the patient was shaved, prepped, and draped using the usual sterile technique. a sterile 16-french foley catheter was then placed with clear urine drained. a midline infraumbilical incision was performed by using a #10 scalpel blade. the rectus fascia and the subcutaneous space were opened by using the bovie. transversalis fascia was opened in the midline and the retropubic space and the paravesical space were developed bluntly. a bookwalter retractor was then placed. the area of the obturator lymph nodes were carefully inspected and no suspicious adenopathy was detected. given this patient's low gleason score and low psa with a solitary core biopsy positive, the decision was made to not perform bilateral lymphadenectomy. the endopelvic fascia was opened bilaterally by using the metzenbaum scissors. opening was enlarged by using sharp dissection. small perforating veins from the prostate into the lateral pelvic wall were controlled by using bipolar coagulation device. the dorsal aspect of the prostate was bunched up by using 2-0 silk sutures. the deep dorsal vein complex was bunched up by using allis also and ligated by using 0 vicryl suture in a figure-of-eight fashion. with the prostate retracted cephalad, the deep dorsal vein complex was transected superficially using the bovie. deeper near the urethra, the dorsal vein complex was transected by using metzenbaum scissors. the urethra could then be easily identified. nearly two-third of the urethra from anteriorly to posteriorly was opened by using metzenbaum scissors. this exposed the blue foley catheter. anastomotic sutures were then placed on to the urethral stump using 2-0 monocryl suture. six of these were placed evenly spaced out anteriorly to posteriorly. the foley catheter was then removed. this allowed for better traction of the prostate laterally. lateral pelvic fascia was opened bilaterally. this effectively released the neurovascular bundle from the apex to the base of the prostate. continued dissection from the lateral pelvic fascia deeply opened up the plane into the perirectal fat. the prostate was then dissected from laterally to medially from this opening in the perirectal fat. the floor of the urethra posteriorly and the rectourethralis muscle was then transected just distal to the prostate. maximal length of ureteral stump was preserved. the prostate was carefully lifted cephalad by using gentle traction with fine forceps. the prostate was easily dissected off the perirectal fat using sharp dissection only. absolutely, no traction to the neurovascular bundle was evident at any point in time. the dissection was carried out easily until the seminal vesicles could be visualized. the prostate pedicles were controlled easily by using multiple medium clips in 4 to 5 separate small bundles on each side. the bladder neck was then dissected out by using a bladder neck dissection method. unfortunately, most of the bladder neck fiber could not be preserved due to the patient's anatomy. once the prostate had been separated from the bladder in the area with the bladder neck, dissection was carried out posteriorly to develop a plane between the bladder and the seminal vesicles. this was developed without any difficulty. both vas deferens were identified, hemoclipped and transected. the seminal vesicles on both sides were quite large and a decision was made to not completely dissect the tip off, as it extended quite deeply into the pelvis. about two-thirds of the seminal vesicles were able to be removed. the tip was left behind. using the bipolar gyrus coagulation device, the seminal vesicles were clamped at the tip sealed by cautery and then transected. this was performed on the left side and then the right side. this completely freed the prostate. the prostate was sent for permanent section. the opening in the bladder neck was reduced by using two separate 2-0 vicryl sutures. the mucosa of the bladder neck was everted by using 4-0 chromic sutures. small amount of bleeding around the area of the posterior bladder wall was controlled by using suture ligature. the ureteral orifice could be seen easily from the bladder neck opening and was completely away from the everting sutures. the previously placed anastomotic suture on the urethral stump was then placed on the corresponding position on the bladder neck. this was performed by using a french ***** needle. a 20-french foley catheter was then inserted and the sutures were sequentially tied down. a 15 ml of sterile water was inflated to balloon. the bladder anastomosis to the urethra was performed without any difficulty. a 19-french blake drain was placed in the left pelvis exiting the right inguinal region. all instrument counts, lap counts, and latex were verified twice prior to the closure. the rectus fascia was closed in running fashion using #1 pds. subcutaneous space was closed by using 2-0 vicryl sutures. the skin was reapproximated by using metallic clips. the patient tolerated the procedure well and was transferred to the recovery room in stable condition.

preoperative diagnosis: , anterior cruciate ligament rupture.,postoperative diagnoses:,1. anterior cruciate ligament rupture.,2. medial meniscal tear.,3. medial femoral chondromalacia.,4. intraarticular loose bodies.,procedure performed:,1. arthroscopy of the left knee was performed with the anterior cruciate ligament reconstruction.,2. removal of loose bodies.,3. medial femoral chondroplasty.,4. medial meniscoplasty.,operative procedure: ,the patient was taken to the operative suite, placed in supine position, and administered a general anesthetic by the department of anesthesia. following this, the knee was sterilely prepped and draped as discussed for this procedure. the inferolateral and inferomedial portals were then established; however, prior to this, a graft was harvested from the semitendinosus and gracilis region. after the notch was identified, then acl was confirmed and ruptured. there was noted to be a torn, slipped up area of the medial meniscus, which was impinging and impinged on the articular surface. the snare was smoothed out. entire area was thoroughly irrigated. following this, there was noted in fact to be significant degenerative changes from this impingement of the meniscus again to the periarticular cartilage. the areas of the worn away portion of the medial femoral condyle was then debrided and ________ chondroplasty was then performed of this area in order to stimulate bleeding and healing. there were multiple loose bodies noted in the knee and these were then __________ and then removed. the tibial and femoral drill holes were then established and the graft was then put in place, both which locations after a notchplasty was performed. the knee was taken through a full range of motion without any impingement. an endobutton was used for proximal fixation. distal fixation was obtained with an independent screw and a staple. the patient was then taken to postanesthesia care unit at the conclusion of the procedure.,

chief complaint:, colostomy failure. ,history of present illness:, this patient had a colostomy placed 9 days ago after resection of colonic carcinoma. earlier today, he felt nauseated and stated that his colostomy stopped filling. he also had a sensation of "heartburn." he denies vomiting but has been nauseated. he denies diarrhea. he denies hematochezia, hematemesis, or melena. he denies frank abdominal pain or fever. ,past medical history:, as above. also, hypertension. ,allergies:, "fleet enema." ,medications:, accupril and vitamins. ,review of systems:,systemic: the patient denies fever or chills.,heent: the patient denies blurred vision, headache, or change in hearing.,neck: the patient denies dysphagia, dysphonia, or neck pain.,respiratory: the patient denies shortness of breath, cough, or hemoptysis.,cardiac: the patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,gastrointestinal: see above.,musculoskeletal: the patient denies arthritis, arthralgias, or joint swelling.,neurologic: the patient denies difficulty with balance, numbness, or paralysis.,genitourinary: the patient denies dysuria, flank pain, or hematuria.,physical examination: ,vital signs: blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,heent: cranial nerves are grossly intact. there is no scleral icterus. ,neck: no jugular venous distention. ,chest: clear to auscultation bilaterally. ,cardiac: regular rate and rhythm. no murmurs. ,abdomen: soft, nontender, nondistended. bowel sounds are decreased and high-pitched. there is a large midline laparotomy scar with staples still in place. there is no evidence of wound infection. examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. there is no evidence of infection. the mucosa appears normal. there is a small amount of nonbloody stool in the colostomy bag. there are no masses or bruits noted. ,extremities: there is no cyanosis, clubbing, or edema. pulses are 2+ and equal bilaterally. ,neurologic: the patient is alert and awake with no focal motor or sensory deficit noted. ,medical decision making:, failure of colostomy to function may repre- sent an impaction; however, i did not appreciate this on physical examination. there may also be an adhesion or proximal impaction which i cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,an abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,the cbc showed wbc of 9.4 with normal differential. hematocrit is 42.6. i interpret this as normal. amylase is currently pending. ,i have discussed this case with dr. s, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. because of the patient's insurance status, the patient will actually be admitted to dr. d on observation. i have discussed the case with dr. p, who is the doctor on call for dr. d. both dr. s and dr. p have been informed of the patient's condition and are aware of his situation. ,final impression:, bowel obstruction, status post colostomy. ,disposition:, admission to observation. the patient's condition is good. he is hemodynamically stable.

procedures:,1. chest x-ray on admission, no acute finding, no interval change.,2. ct angiography, negative for pulmonary arterial embolism.,3. nuclear myocardial perfusion scan, abnormal. reversible defect suggestive of ischemia, ejection fraction of 55%.,diagnoses on discharge:,1. chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.,2. coronary artery disease, abnormal nuclear scan, discussed with cardiology dr. x, who recommended to discharge the patient and follow up in the clinic.,3. diabetes mellitus type 2.,4. anemia, hemoglobin and hematocrit stable.,5. hypokalemia, replaced.,6. history of coronary artery disease status post stent placement 2006-2008.,7. bronchitis.,hospital course: ,the patient is a 65-year-old american-native indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, copd, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea. the patient started on iv steroid, bronchodilator as well as antibiotics.,he also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea. he was evaluated by cardiology dr. x, who proceeded with stress test. stress test reported positive for reversible ischemia, but cardiology decided to follow up the patient in the clinic. the patient's last cardiac cath was in 2008.,the patient clinically significantly improved and wants to go home. his hemoglobin on admission was 8.8, and has remained stable. he is afebrile, hemodynamically stable.,allergies: , lisinopril and penicillin.,medications on discharge:,1. prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.,2. levaquin 750 mg p.o. daily for 5 more days.,3. protonix 40 mg p.o. daily.,4. the patient can continue other current home medications at home.,followup appointments:,1. recommend to follow up with cardiology dr. x's office in a week.,2. the patient is recommended to see hematology dr. y in the office for workup of anemia.,3. follow up with primary care physician's office tomorrow.,special instructions:,1. if increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.,2. discussed about discharge plan, instructions with the patient by bedside. he understands and agreed. also discussed discharge plan instructions with the patient's nurse.

preoperative diagnosis:, low back syndrome - low back pain with left greater than right lower extremity radiculopathy.,postoperative diagnosis:, same.,procedure:,1. nerve root decompression at l45 on the left side.,2. tun-l catheter placement with injection of steroid solution and marcaine at l45 nerve roots left.,3. interpretation of radiograph.,anesthesia: , iv sedation with versed and fentanyl.,estimated blood loss:, none.,complications:, none.,indication for procedure: , severe and excruciating pain in the lumbar spine and lower extremity. mri shows disc pathology as well as facet arthrosis.,summary of procedure: , the patient was admitted to the operating room, 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. after adequate iv sedation with versed and fentanyl the procedure was begun.,the lumbar sacral region was prepped and draped in sterile fashion with betadine and four sterile towels. after the towels were places then sterile drapes were placed on top of that.,after which time the epimed catheter was then placed, this was done by first repositioning the c-arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at l5, verifying the sacral hiatus. the skin over the sacral hiatus was then injected with 1% lidocaine and an #18-gauge needle was used for skin puncture. the #18-gauge needle was inserted off of midline. a #16-gauge rk needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed. negative aspiration was carefully performed. omnipaque 240 dye was then injected through the #16-gauge rk needle. the classical run off was noted. a filling defect was noted @ l45 nerve root on the left side. after which time 10 cc of 0.25% marcaine/triamcinolone (9/1 mixture) was then infused through the 16 r-k needle. some additional lyses of adhesions were visualized as the local anesthetic displaced the omnipaque 240 dye using this barbotage technique.,an epimed tun-l catheter was then inserted through the #16-gauage r-k needle and threaded up to the l45 interspace under continuous fluoroscopic guidance. as the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized. the tip of the catheter was noted to be @ l45 level on the left side. after this the #16-gauge rk needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the l45 nerve root region on the left side. after this was successfully done, the catheter was then secured in place; this was done with neosporin ointment, a split 2x2, op site and hypofix tape. the catheter was then checked with negative aspiration and the omnipaque 240 dye was then injected. the classical run off was noted in the lumbar region. some lyses of adhesions were also visualized at this time with barbotage technique. good dye spread was noted to extend one level above and one level below the l45 nerve root and bilateral spread was noted. nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect. after which time negative aspiration was again performed through the epimed® tun-l catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose. approximately 3 minutes elapsed and then the remaining 7 cc were infused (solution consisting of 8 cc of 0.25% marcaine, 2 cc of triamcinolone and 1 cc of wydase.) the catheter was then capped with a bacterial filter. the patient was noted to have tolerated the procedure well without any complications.,interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed. a filling defect was seen at the l45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure. this verified positive nerve root decompression. the tip of the epimed tun l catheter was noted to be at l45 level on the left side. positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of omnipaque 240 dye was noted. this patient did not report any problems and reported pain reduction.

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

preoperative diagnosis:, right buccal and canine's base infection from necrotic teeth. icd9 code: 528.3.,postoperative diagnosis: , right buccal and canine's base infection from necrotic teeth. icd9 code: 528.3.,procedure: , incision and drainage of multiple facial spaces; cpt code: 40801. surgical removal of the following teeth. the teeth numbers 1, 2, 3, 4, and 5. cpt code: 41899 and dental code 7210.,specimens: , cultures and sensitivities were taken and sent for aerobic and anaerobic to the micro lab.,drains: ,a 1.5 inch penrose drain placed in the right buccal and canine space.,estimated blood loss:, 40 ml.,fluid: ,700 ml of crystalloid.,complications: ,none.,condition: ,the patient was extubated breathing spontaneously to the pacu in good condition.,indication for procedure: ,the patient is a 41-year-old that has a recent history of toothache and tooth pain. she saw her dentist in sacaton before thanksgiving who placed her on antibiotics and told her to return to the clinic for multiple teeth extractions. the patient neglected to return to the dentist until this weekend for iv antibiotics and definitive treatment. she noticed on friday that her face was starting to swell up a little bit and it progressively got worse. the patient was admitted to the hospital on monday for iv antibiotics. oral surgery was consulted today to aid in the management of the increased facial swelling and tooth pain. the patient was worked up preoperatively by anesthesia and oromaxillary facial surgery. it was determined that she would benefit from being having multiple teeth removed and drainage of the facial abscess under general anesthesia. risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,description of procedure:, the patient was taken to the operating room and laid on the operating room table on supine fashion. asa monitors were attached as stated. general anesthesia was induced with iv anesthetic and maintained with a nasal endotracheal intubation and inhalation of anesthetics. the patient was prepped and draped in usual oromaxillary facial surgery fashion.,an 18-gauze needle of 20 ml syringe was used to aspirate the pus out of the right buccal space. this pus was then cultured and sent to micro lab for cultures and sensitivities. approximately 7 ml of 1% lidocaine with 1:1000 epinephrine was injected in the maxillary vestibule and palate. after waiting appropriate time for local anesthesia to take affect a moist latex sponge was placed in the posterior oropharynx to throat pack throughout the case. mouth rinse was then poured into the oral cavity. the mucosa was scrubbed with a tooth brush and peridex was evacuated with suction. using a #15 blade a clavicular incision from tooth #5 back to 1 with tuberosity release was performed.,a full thickness mucoperiosteal flap was developed and approximately 6 ml of pus was instantly drained from the buccal space. it was noted on exam that the tooth #1 was fractured off to the gum line with gross decay. tooth #2, 3, 4, and 5 had pus leaking from the clavicular epithelium and had rampant decay on tooth #2 and 3 and some mobility on teeth #4 and 5. it was decided that teeth #1 through 5 would be surgically removed to ensure that all potential teeth causing the abscess were removed. using a rongeur both buccal bone and the tooth 1, 2, 3, 4, and 5 were surgically removed. the extraction sites were curetted with curettes and the bone was smoothed with the rongeur and the bone file. dissection was then carried further up in the canine space and the face was palpated extra orally from the temporalis muscle down to the infraorbital rim and more pus was expressed. this site was then irrigated with copious amounts of sterile water. there was still noted to be induration in the buccal mucosa so #15 blade was used anterior to stensen duct. a 2 cm incision was made and using a hemostat blunt dissection in to the buccal mucosa was performed. a little-to-no pus was received. using a half-inch penrose the drain was placed up on the anterior border of the maxilla and zygoma and sutured in place with 2-0 ethilon suture. remainder of the flap was left open to drain. further examination of the floor of mouth was soft. the lateral pharynx was nonindurated or swollen. at this point, the throat pack was removed and og tube was placed and the stomach contents were evacuated. the procedure was then determined to be over. the patient was extubated, breathing spontaneously, and transferred to the pacu in excellent condition.

history:, the patient is 14 months old, comes in with a chief complaint of difficulty breathing. difficulty breathing began last night. he was taken to emergency department where he got some xopenex, given a prescription for amoxicillin and discharged home. they were home for about an hour when he began to get worse and they drove here to children's hospital. he has a history of reactive airway disease. he has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing. he was diagnosed with pneumonia back on 06/12/2007 here in the emergency department but was not admitted at that time. he has been on albuterol off and on over that period. he has had fever overnight. no vomiting, no diarrhea. increased work of breathing with retractions and audible wheezes noted and thus brought to the emergency department. normal urine output. no rashes have been seen.,past medical history: , as noted above. no hospitalizations, surgeries, allergies.,medications: , xopenex.,immunizations:, up-to-date.,birth history:, the child was full term, no complications, home with mom. no surgeries.,family history: , negative.,social history: , no smokers or pets in the home. no ill contacts, no travel, no change in living condition.,review of systems: , ten are asked, all are negative, except as noted above.,physical examination:,vital signs: temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,general: the child is awake, alert, in moderate respiratory distress.,heent: pupils equal, round, reactive to light. extraocular movements are intact. the tms are clear. the nares show some dry secretions. audible congestion and wheezing is noted. mucous membranes are dry. throat is clear. no oral lesions noted.,neck: supple without lymphadenopathy or masses. trachea is midline.,lungs: show inspiratory and expiratory wheezes in all fields. audible wheezes are noted. there are intercostal and subcostal retractions and suprasternal muscle use is noted.,heart: shows tachycardia. regular rhythm. normal s1, s2. no murmur.,abdomen: soft, nontender. positive bowel sounds. no guarding. no rebound. no hepatosplenomegaly.,extremities: capillary refill is brisk. good distal pulses.,neurologic: cranial nerves ii through xii intact. moves all 4 extremities equally and normally.,hospital course: , the child has an iv placed. i felt the child was dehydrated on examination. we gave 20 ml/kg bolus of normal saline over one hour. the child was given solu-medrol 2 mg/kg iv. he was initially started on unit dose albuterol and atrovent but high-dose albuterol for continuous nebulization was ordered.,a portable chest x-ray was done showing significant peribronchial thickening bilaterally. normal heart size. no evidence of pneumothorax. no evidence of focal pneumonia. after 3 unit dose of albuterol/atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time. the child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour. the child's pulse ox on breathing treatments with 100% oxygen was 100%. respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea. the child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,the child has failed outpatient therapy at this time. after 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout. after i removed the oxygen, the pulse ox was down at 91% indicating hypoxia. the child has a normal level of alertness; however, has not had any vomiting here. i spoke with dr. x, on call for hospitalist service. she has come down and evaluated the patient. we both feel that since this child had two er visits this last month, one previous er visit within the last 5 hours, we should admit the child for continued albuterol treatments, iv steroids, and asthma teaching for the family. the child is admitted in a stable condition.,differential diagnoses: ,ruled out pneumothorax, pneumonia, bronchiolitis, croup.,time spent: ,critical care time outside billable procedures was 45 minutes with this patient.,impression: ,status asthmaticus, hypoxia.,plan: ,admitted to pediatrics.

preoperative diagnosis: , left testicular torsion, possibly detorsion.,postoperative diagnosis: , left testicular torsion, possibly detorsion.,procedure: , left scrotal exploration with detorsion. already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,anesthetic:, a 0.25% marcaine local wound insufflation per surgeon, 15 ml of toradol.,findings:, congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally. no testis necrosis.,estimated blood loss:, 5 ml.,fluids received: , 300 ml of crystalloid.,tubes and drains:, none.,specimens: , no tissues sent to pathology.,counts:, sponges and needle counts were correct x2.,indications of operation: , the patient is a 4-year-old boy with abrupt onset of left testicular pain. he has had a history of similar onset. apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, i recommended an exploration.,description of operation:, the patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified. once he was anesthetized, he was placed in supine position and sterilely prepped and draped. superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery. electrocautery was used for hemostasis. the subdartos pouch was created with curved tenotomy scissors. the tunica vaginalis was then delivered, incised, and testis was delivered. the testis itself with a bell-clapper deformity. there was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord. the penis fascia was cauterized and subdartos pouch was created. the upper aspect of fascia was then closed with pursestring suture of 4-0 chromic. the testis was then placed into the scrotum in a proper orientation. no tacking sutures within the testis itself were used. the tunica vaginalis; however, was wrapped perfectly behind the back of the testis. a similar procedure was performed on the right side. again, an appendix testis was cauterized. no torsion was seen. he also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture. the local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% marcaine. the scrotal wall was then closed with subcuticular closure of #4-0 chromic. dermabond tissue adhesive was then used. the patient tolerated the procedure well. he was given iv toradol and was taken to the recovery room in stable condition.

preoperative diagnoses:, prior history of anemia, abdominal bloating.,postoperative diagnosis:, external hemorrhoids, otherwise unremarkable colonoscopy.,premedications:, versed 5 mg, demerol 50 mg iv.,report of procedure:, digital rectal exam revealed external hemorrhoids. the colonoscope was inserted into the rectal ampulla and advanced to the cecum. the position of the scope within the cecum was verified by identification of the appendiceal orifice. the cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal. the scope was retroflexed in the rectum and no abnormality was seen. so the scope was straightened, withdrawn, and the procedure terminated.,endoscopic impression:,1. normal colonoscopy.,2. external hemorrhoids.

preoperative diagnoses:, ,1. recurrent intractable low back and left lower extremity pain with history of l4-l5 discectomy.,2. epidural fibrosis with nerve root entrapment.,postoperative diagnoses:, ,1. recurrent intractable low back and left lower extremity pain with history of l4-l5 discectomy.,2. epidural fibrosis with nerve root entrapment.,operation performed:, left l4-l5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,anesthesia:, local/iv sedation.,complications:, none.,summary: ,the patient in the operating room, status post transforaminal epidurogram (see operative note for further details). using ap and lateral fluoroscopic views to confirm the needle location the superior most being in the left l4 neural foramen and the inferior most in the left l5 neural foramen, 375 units of wydase was injected through each needle. after two minutes, 3.5 cc of 0.5% marcaine and 80 mg of depo-medrol was injected through each needle. these needles were removed and the patient was discharged in stable condition.

preoperative diagnosis:, ageing face.,postoperative diagnosis: , ageing face.,operative procedure:,1. cervical facial rhytidectomy.,2. quadrilateral blepharoplasty.,3. autologous fat injection to the upper lip.,operations performed:,1. cervical facial rhytidectomy.,2. quadrilateral blepharoplasty.,3. autologous fat injection to the upper lip - donor site, abdomen.,indication: ,this is a 62-year-old female for the above-planned procedure. she was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied. full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,procedure: , the patient was brought to the operative room under satisfaction, and she was placed supine on the or table. administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen. this included the neck accordingly.,two platysmal sling application and operating headlight were utilized. hemostasis was controlled with the pinpoint cautery along with suction bovie cautery.,the first procedure was performed was that of a quadrilateral blepharoplasty. markers were applied to both upper lids in symmetrical fashion. the skin was excised from the right upper lid first followed by appropriate muscle resection. minimal fat removed from the medial upper portion of the eyelid. hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture. attention was then turned to the lower lid. a classic skin muscle flap was created accordingly. fat was resected from the middle, medial, and lateral quadrant. the fat was allowed to open drain the arcus marginalis for appropriate contour. hemostasis was controlled with the pinpoint cautery accordingly. skin was redraped with a conservative amount resected. running closure with 7-0 nylon was accomplished without difficulty. the exact same procedure was repeated on the left upper and lower lid.,after completion of this portion of the procedure, the lag lid was again placed in the eyes. eye mass was likewise clamped. attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure. the right face was first operated. it was injected with a 0.25% marcaine 1:200,000 adrenaline. a submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula. she had minimal subcutaneous extra fat as noted. attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline. the flap was elevated without difficulty with various facelift scissors. hemostasis was controlled again with a pinpoint cautery as well as suction bovie cautery.,the exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision. rectus plication in the midline with a running 4-0 mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery. the submental incision was closed with a running 7-0 nylon over 5-0 monocryl.,attention was then turned to closure of the bilateral facelift incisions after appropriate smas plication. the left side of face was first closed followed by interrupted smas plication utilizing 4-0 wide mersilene. the skin was draped appropriately and appropriate tissue was resected. a 7-mm 9-0 french drain was utilized accordingly prior to closure of the skin with interrupted 4-0 monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface. preauricular interrupted 5-0 monocryl was followed by running 7-0 nylon. the hairline temporal incision was closed with running 5-0 nylon. the exact same closure was accomplished on the right side of the face with a same size 7-mm french drain.,the patient's dressing consisted of adaptic polysporin ointment followed by kerlix wrap with a 3-inch ace.,the lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described. suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly. approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly. tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure. the incision site was closed with 7-0 nylon.,the patient tolerated the procedure well and was transferred to the recovery room in stable condition with foley catheter in position.,the patient will be admitted for overnight short stay through the cosmetic package procedure. she will be discharged in the morning.,estimated blood loss was less than 75 cc. no complications noted, and the patient tolerated the procedure well.

grade ii: atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,grade iii: atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,grade iv: the vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,right carotid system: , the common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. the internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. the external carotid artery shows no disease. the vertebral was present and was antegrade.,left carotid system: , the common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. the external carotid artery shows no disease. the vertebral was present and was antegrade.,impression:, bilateral atherosclerotic changes with no evidence for any significant obstructive disease.

indications: ,chest pain.,stress technique:,

exam: , ct stone protocol.,reason for exam:, history of stones, rule out stones.,technique: , noncontrast ct abdomen and pelvis per renal stone protocol.,findings: , correlation is made with a prior examination dated 01/20/09.,again identified are small intrarenal stones bilaterally. these are unchanged. there is no hydronephrosis or significant ureteral dilatation. there is no stone along the expected course of the ureters or within the bladder. there is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith. there is no asymmetric renal enlargement or perinephric stranding.,the appendix is normal. there is no evidence of a pericolonic inflammatory process or small bowel obstruction.,scans through the pelvis disclose no free fluid or adenopathy.,lung bases aside from very mild dependent atelectasis appear clear.,given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. the gallbladder is present. there is no abdominal free fluid or pathologic adenopathy.,impression:,1. bilateral intrarenal stones, no obstruction.,2. normal appendix.

preoperative diagnosis: , acute cholecystitis.,postoperative diagnosis:, acute cholecystitis.,procedure performed:, laparoscopic cholecystectomy.,anesthesia: , general.,estimated blood loss:, zero.,complications: , none.,procedure: ,the patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position. the abdominal area was prepped and draped in the usual sterile fashion. a small skin incision was made below the umbilicus. it was carried down in the transverse direction on the side of her old incision. it was carried down to the fascia. an open pneumoperitoneum was created with hasson technique. three additional ports were placed in the usual fashion. the gallbladder was found to be acutely inflamed, distended, and with some necrotic areas. it was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips. the gallbladder was then taken down from the gallbladder fossa with electrocautery. there was some bleeding from the gallbladder fossa that was meticulously controlled with a bovie. the gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones. the fascia had to be opened. the gallbladder had to be opened, and the stones had to be extracted carefully. when it was completed, i went back to the abdomen and achieved complete hemostasis. the ports were then removed under direct vision with the scope. the fascia of the umbilical wound was closed with a figure-of-eight 0 vicryl. all the incisions were injected with 0.25% marcaine, closed with 4-0 monocryl, steri-strips, and sterile dressing.,the patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.

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.,

chief complaint:, followup on diabetes mellitus, status post cerebrovascular accident.,subjective:, this is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. we have done emg studies. he has noticed it since his stroke about five years ago. he has been to see a neurologist. we have tried different medications and it just does not seem to help. he checks his blood sugars at home two to three times a day. he kind of adjusts his own insulin himself. re-evaluation of symptoms is essentially negative. he has a past history of heavy tobacco and alcohol usage.,medications:, refer to chart.,allergies:, refer to chart.,physical examination: ,vitals: wt; 118 lbs, b/p; 108/72, t; 96.5, p; 80 and regular. ,general: a 70-year-old male who does not appear to be in acute distress but does look older than his stated age. he has some missing dentition.,skin: dry and flaky. ,cv: heart tones are okay, adequate carotid pulsations. he has 2+ pedal pulse on the left and 1+ on the right.,lungs: diminished but clear.,abdomen: scaphoid.,rectal: his prostate check was normal per dr. gill.,neuro: sensation with monofilament testing is better on the left than it is on the right.,impression:,1. diabetes mellitus.,2. neuropathy.,3. status post cerebrovascular accident.,plan:, refill his medications x 3 months. we will check an a1c and bmp. i have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. we will check a psa. continue with yearly eye exams, foot exams, accu-cheks, and we will see him in three months and p.r.n.

preoperative diagnosis: , appendicitis.,postoperative diagnosis:, appendicitis.,procedure performed: , laparoscopic appendectomy.,anesthesia: , general.,complications: , none.,estimated blood loss:, minimal.,procedure in detail: , the patient was prepped and draped in sterile fashion. infraumbilical incision was performed and taken down to the fascia. the fascia was incised. the peritoneal cavity was carefully entered. two other ports were placed in the right and left lower quadrants. the appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the endo gia stapler and brought out through the umbilical wound with the endocatch bag.,all hemostasis was further reconfirmed. no leakage of enteral contents was noted. all trocars were removed under direct visualization. the umbilical fascia was closed with interrupted 0 vicryl sutures. the skin was closed with 4-0 monocryl subcuticular stitch and dressed with steri-strips and 4 x 4's. the patient was extubated and taken to the recovery area in stable condition. the patient tolerated the procedure well.

procedure: , fiberoptic bronchoscopy.,preoperative diagnosis:, right lung atelectasis.,postoperative diagnosis:, extensive mucus plugging in right main stem bronchus.,procedure in detail:, fiberoptic bronchoscopy was carried out at the bedside in the medical icu after versed 0.5 mg intravenously given in 2 aliquots. the patient was breathing supplemental nasal and mask oxygen throughout the procedure. saturations and vital signs remained stable throughout. a flexible fiberoptic bronchoscope was passed through the right naris. the vocal cords were visualized. secretions in the larynx were as aspirated. as before, he had a mucocele at the right anterior commissure that did not obstruct the glottic opening. the ports were anesthetized and the trachea entered. there was no cough reflex helping explain the propensity to aspiration and mucus plugging. tracheal secretions were aspirated. the main carinae were sharp. however, there were thick, sticky, grey secretions filling the right mainstem bronchus up to the level of the carina. this was gradually lavaged clear. saline and mucomyst solution were used to help dislodge remaining plugs. the airways appeared slightly friable, but were patent after the airways were suctioned. o2 saturations remained in the mid-to-high 90s. the patient tolerated the procedure well. specimens were submitted for microbiologic examination. despite his frail status, he tolerated bronchoscopy quite well.

preoperative diagnoses:,1. intrauterine pregnancy at 39 weeks.,2. history of previous cesarean section x2. the patient desires a repeat section.,3. chronic hypertension.,4. undesired future fertility. the patient desires permanent sterilization.,postoperative diagnoses:,1. intrauterine pregnancy at 39 weeks.,2. history of previous cesarean section x2. the patient desires a repeat section.,3. chronic hypertension.,4. undesired future fertility. the patient desires permanent sterilization.,procedure performed: ,repeat cesarean section and bilateral tubal ligation.,anesthesia: , spinal.,estimated blood loss:, 800 ml.,complications: ,none.,findings: , male infant in cephalic presentation with anteflexed head, apgars were 2 at 1 minute and 9 at 5 minutes, 9 at 10 minutes, and weight 7 pounds 8 ounces. normal uterus, tubes, and ovaries were noted.,indications: ,the patient is a 31-year-old gravida 5, para 4 female, who presented to repeat cesarean section at term. the patient has a history of 2 previous cesarean sections and she desires a repeat cesarean section, additionally she desires permanent fertilization. the procedure was described to the patient in detail including possible risks of bleeding, infection, injury to surrounding organs, and the possible need for further surgery and informed consent was obtained.,procedure note: , the patient was taken to the operating room where spinal anesthesia was administered without difficulty. the patient was prepped and draped in the usual sterile fashion in the dorsal supine position with a leftward tilt. a pfannenstiel skin incision was made with the scalpel and carried through to the underlying layer of fascia using the bovie. the fascia was incised in the midline and extended laterally using mayo scissors. kocher clamps were used to elevate the superior aspect of the fascial incision, which was elevated, and the underlying rectus muscles were dissected off bluntly and using mayo scissors. attention was then turned to the inferior aspect of the fascial incision, which in similar fashion was grasped with kocher clamps, elevated, and the underlying rectus muscles were dissected off bluntly and using the bovie. the rectus muscles were dissected in the midline.,the peritoneum was identified and entered using metzenbaum scissors; this incision was extended superiorly and inferiorly with good visualization of the bladder. the bladder blade was inserted. the vesicouterine peritoneum was identified and entered sharply using metzenbaum scissors. this incision was extended laterally and the bladder flap was created digitally. the bladder blade was reinserted. the lower uterine segment was incised in a transverse fashion using the scalpel and extended using bandage scissors as well as manual traction.,clear fluid was noted. the infant was subsequently delivered using a kelly vacuum due to anteflexed head and difficulty in delivering the infant's head without the kelly. the nose and mouth were bulb suctioned. the cord was clamped and cut. the infant was subsequently handed to the awaiting nursery nurse. the placenta was delivered spontaneously intact with a three-vessel cord noted. the uterus was exteriorized and cleared of all clots and debris. the uterine incision was repaired in 2 layers using 0 chromic sutures. hemostasis was visualized. attention was turned to the right fallopian tube, which was grasped with babcock clamp using a modified pomeroy method, a 2 cm of segment of tube ligated x2, transected and specimen was sent to pathology. attention was then turned to the left fallopian tube, which was grasped with babcock clamp again using a modified pomeroy method, a 2 cm segment of tube was ligated x2 and transected. hemostasis was visualized bilaterally. the uterus was returned to the abdomen, both fallopian tubes were visualized and were noted to be hemostatic. the uterine incision was reexamined and it was noted to be hemostatic. the pelvis was copiously irrigated. the rectus muscles were reapproximated in the midline using 3-0 vicryl. the fascia was closed with 0 vicryl suture, the subcutaneous layer was closed with 3-0 plain gut, and the skin was closed with staples. sponge, lap, and instrument counts were correct x2. the patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.

reason for examination: , cardiac arrhythmia.,interpretation: , no significant pericardial effusion was identified.,the aortic root dimensions are within normal limits. the four cardiac chambers dimensions are within normal limits. no discrete regional wall motion abnormalities are identified. the left ventricular systolic function is preserved with an estimated ejection fraction of 60%. the left ventricular wall thickness is within normal limits.,the aortic valve is trileaflet with adequate excursion of the leaflets. the mitral valve and tricuspid valve motion is unremarkable. the pulmonic valve is not well visualized.,color flow and conventional doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an rv systolic pressure calculated to be 28 mmhg. doppler interrogation of the mitral in-flow pattern is within normal limits for age.,impression:,1. preserved left ventricular systolic function.,2. mild mitral regurgitation.,3. mild tricuspid regurgitation.

preoperative diagnosis: , hematemesis in a patient with longstanding diabetes. ,postoperative diagnosis: ,mallory-weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis.,procedure: , the procedure, indications explained and he understood and agreed. he was sedated with versed 3, demerol 25 and topical hurricane spray to the oropharynx. a bite block was placed. the pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision. esophagus revealed distal ulcerations. additionally, the patient had a mallory-weiss tear. this was subjected to bicap cautery with good ablation. the stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting. there were no ulcerations or erosions in the stomach. the duodenum was entered, which was unremarkable. the instrument was then removed. the patient tolerated the procedure well with no complications.,impression: , mallory-weiss tear, successful bicap cautery. ,we will keep the patient on proton pump inhibitors. the patient will remain on antiemetics and be started on a clear liquid diet.

admission diagnoses:,1. menorrhagia.,2. uterus enlargement.,3. pelvic pain.,discharge diagnosis: , status post vaginal hysterectomy.,complications: , none.,brief history of present illness: , this is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period. she also had symptoms of back pain, dysmenorrhea, and dysuria. the symptoms had been worsening over time. the patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,procedure:, the patient underwent a total vaginal hysterectomy.,hospital course: ,the patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy. the procedure preceded as planned without complication. uterus was sent for pathologic analysis. the patient was monitored in the hospital, 2 days postoperatively. she recovered quite well and vitals remained stable.,laboratory studies, h&h were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,the patient was ready for discharge on monday morning of 09/06/2007.,laboratory findings: , please see chart for full studies during admission.,disposition: ,the patient was discharged to home in stable condition. she was instructed to follow up in the office postoperatively.

preoperative diagnosis:, infected sebaceous cyst, right neck.,postoperative diagnosis:, infected sebaceous cyst, right neck.,procedure: , the patient was electively taken to the operating room after obtaining an informed consent. with a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion. the elliptical incision was performed around the draining tract. immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue. all the necrotic tissue was excised together with an ellipse of skin. hemostasis was achieved with a cautery. the cavity was irrigated with normal saline. at the end of procedure, there was a good size around cavity that was packed with iodoform gauze. one skin suture was grazed for approximation.,a bulky dressing was applied.,the patient tolerated the procedure well. estimated blood loss was negligible and the patient was sent to same day surgery for recovery.

subjective:, the patient has recently had an admission for pneumonia with positive blood count. she was treated with iv antibiotics and p.o. antibiotics; she improved on that. she was at home and doing quite well for approximately 10 to 12 days when she came to the er with a temperature of 102. she was found to have strep. she was treated with penicillin and sent home. she returned about 8 o'clock after vomiting and a probable seizure. temperature was 104.5; she was lethargic after that. she had an lp, which was unremarkable. she had blood cultures, which have not grown anything. the csf has not grown anything at this point.,physical examination:, she is alert, recovering from anesthesia. head, eyes, ears, nose and throat are unremarkable. chest is clear to auscultation and percussion. abdomen is soft. extremities are unremarkable.,lab studies: , white count in the emergency room was 9.8 with a slight shift. csf glucose was 68, protein was 16, and there were no cells. the gram-stain was unremarkable.,assessment: , i feel that this patient has a febrile seizure.,plan: , my plan is to readmit the patient to control her temperature and assess her white count. i am going to observe her overnight.

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.,

admitting diagnoses:, left renal cell carcinoma, left renal cyst.,discharge diagnosis:, left renal cell carcinoma, left renal cyst.,secondary diagnoses:,1. chronic obstructive pulmonary disease.,2. coronary artery disease.,procedures: , robotic-assisted laparoscopic left renal cyst decortication and cystoscopy.,history of present illness: , mr. abc is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts. he has undergone mri of the abdomen on june 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma. of note, there are no other enhancing solid masses seen on this mri. after discussion of multiple management strategies with the patient including:,1. left partial nephrectomy.,2. left radical nephrectomy.,3. left renal cyst decortication. the patient is likely to undergo the latter procedure.,hospital course: ,the patient was admitted to undergo left renal cyst decortication as well as a cystoscopy. intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed. the contents were aspirated and careful dissection of the cyst wall was performed. multiple specimens of the cyst wall were sent for pathology. approximately one liter of cystic fluid was drained during the procedure. the renal bed was inspected for hemostasis, which appear to be adequate. there were no complications with the procedure. single jp drain was left in place. additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra. furthermore, no gross lesions were encountered in the bladder. the patient left or with transfer to the pacu and subsequently to the hospital floor.,the patient's postoperative course was relatively uneventful. his diet and activity were gradually advanced without complication. on postoperative day #2, he was passing flatus and has had bowel movements. his jackson-pratt drain was discontinued on postoperative day #3 that being the day of discharge. his foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly. at the time of discharge, he was afebrile. his vital signs indicated hemodynamic stability and he had no evidence of infection. the patient was instructed to follow up with dr. xyz on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,disposition: , to home.,discharge condition:, good.,medications: ,please see attached medication list.,instructions: , the patient was instructed to contact dr. xyz's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,followup: , the patient will follow up with dr. xyz for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.

chief complaint:, arm and leg jerking.,history of present illness: ,the patient is a 10-day-old caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. mom denies any apnea, perioral cyanosis, or color changes. these movements are without any back arching. they mainly occur during sleep, so mom is unaware of any eye rolling. mom is able to wake the patient up during this periods and stop the patient's extremity movements.,otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. she is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. she is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,review of systems:, negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. this patient has developed some upper airway congestion in the past day. she has not had any vomiting or diarrhea. per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. this patient has not had any rashes. mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees fahrenheit. otherwise, the above history of present illness and other review of systems negative.,birth/past medical history: , the patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. there were no complications during pregnancy such as diabetes or hypertension. prenatal care started at approximately 3 weeks, and mom maintained all visits. she also denies any smoking, alcohol, or drug use during the pregnancy. mom was gbs status positive, but denies any other infections such as urinary tract infections. she did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. after delivery, this patient did not receive antibiotics secondary to "borderline labs." she was jaundiced after birth and received photo treatments. her discharge bilirubin level was approximately 11. mom and child stayed in the hospital for approximately 3-1/2 days.,mom denies any history of sexually transmitted disease in her or dad. she specifically denies any blistering, herpetic genital lesions. she does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,past surgical history:, negative.,allergies: , no known drug allergies.,medications: , none.,social history: , at home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. all the residents at home are sick currently with cold, cough, runny nose, except for mom. at home also live 2 dogs and 2 outside cats. mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,family history:, dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. the patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. the maternal grandmother is notable for hypertension and diabetes. there are no other children in the family who see a specialist or no child death less than 1 year of age.,physical examination:

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.,

subjective:, the patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. she has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. since her last visit she has been followed by dr. kumar. those issues are stable. she has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,past medical history:, she has an intolerance to prevacid.,current medications:, evista 60 daily, levothroid 0.05 mg daily, claritin 10 daily, celebrex 200 daily, hctz 25 daily and amitriptyline p.r.n.,past surgical history:, bilateral mastectomies, tonsillectomy, egd, flex sig in 2001 and a heart cath.,family history: , father passed away at 81; mother of multiple myeloma at 83.,social history:, she is married. a 76-year-old who used to smoke a pack a day and quit in 1985. she is retired.,review of systems:, essentially negative in heent, chest, cardiovascular, gi, gu, musculoskeletal, or neurologic.,objective:, temperature is 97.5 degrees. blood pressure is 168/70. pulse is 88. weight is 129 pounds.,general: she is an elderly 76-year-old in no acute distress.,heent: atraumatic. extraocular muscles were intact. pupils equal, round and reactive to light and accommodation. tympanic membranes are clear, dry and intact. sinuses and throat are clear. neck is soft, supple. no meningeal signs are present. no thyromegaly is present.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm without murmur.,abdomen: soft, nontender. bowel sounds are positive. no organomegaly or peritoneal signs are present.,extremities: moving all extremities. peripheral pulses are normal. no edema is present.,neurologic: alert and oriented. cranial nerves ii-xii grossly intact. strength 5+/5 globally. reflexes 2+/iv globally. romberg is negative. there is no numbness, tingling, weakness or other neurologic deficit present.,breasts: surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,back: straight.,skin: clear.,genitalia: deferred as she has been followed by dr. xyz many times this year. she does have a history of some elevated cholesterol.,assessment:,1. hypertension, suboptimal control.,2. hypothyroidism.,3. arthritis.,4. allergic rhinitis.,5. history of kidney stones.,6. osteoporosis.,plan:,1. cbc, complete metabolic profile, ua for hypertension.,2. chest x-ray for history of breast cancer.,3. dexa scan, full body for osteoporosis.,4. flex is up to date.,5. pneumovax has been given in the last five years.,6. lipid profile for elevated cholesterol.,7. refill meds.,8. follow up every three to six months for blood pressure check or sooner p.r.n. problems.

procedure: ,laparoscopic tubal sterilization, tubal coagulation.,preoperative diagnosis: , request tubal coagulation.,postoperative diagnosis: , request tubal coagulation.,procedure: ,under general anesthesia, the patient was prepped and draped in the usual manner. manipulating probe placed on the cervix, changed gloves. small cervical stab incision was made, veress needle was inserted without problem. a 3 l of carbon dioxide was insufflated. the incision was enlarged. a 5-mm trocar placed through the incision without problem. laparoscope placed through the trocar. pelvic contents visualized. a 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline. under direct vision, the trocar was placed in the abdominal cavity. uterus, tubes, and ovaries were all normal. there were no pelvic adhesions, no evidence of endometriosis. uterus was anteverted and the right adnexa was placed on a stretch. the tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation. the tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated. the structure was confirmed to be tube by looking at fimbriated end. the left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it. under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again. tube was confirmed by fimbriated end. gas was lend out of the abdomen. both punctures repaired with 4-0 vicryl and punctures were injected with 0.5% marcaine 10 ml. the patient went to the recovery room in good condition.

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

preoperative diagnosis: , degenerative disk disease at l4-l5 and l5-s1.,postoperative diagnosis:, degenerative disk disease at l4-l5 and l5-s1.,procedure performed: ,anterior exposure diskectomy and fusion at l4-l5 and l5-s1.,anesthesia: , general.,complications:, none.,estimated blood loss: , 150 ml.,procedure in detail: ,patient was prepped and draped in sterile fashion. left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the bovie, and then preperitoneal space was opened. the iliac veins were carefully mobilized medially, and then the l4-l5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by dr. x, was performed after the adequate exposure was gained, and then after this l4-l5 disk space was fused and the l5-s1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed. diskectomy and fusion, which will be separately dictated by dr. x, were performed. once this was completed, all hemostasis was confirmed. the preperitoneal space was reduced. x-ray confirmed adequate positioning and fusion. then the fascia was closed with #1 vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 vicryl subcutaneous tissues and then a 4-0 monocryl subcuticular stitch, then dressed with steri-strips and 4 x 4's. then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.

preoperative diagnosis: , appendicitis.,postoperative diagnosis:, appendicitis.,procedure performed: , laparoscopic appendectomy.,anesthesia: , general.,complications: , none.,estimated blood loss:, minimal.,procedure in detail: , the patient was prepped and draped in sterile fashion. infraumbilical incision was performed and taken down to the fascia. the fascia was incised. the peritoneal cavity was carefully entered. two other ports were placed in the right and left lower quadrants. the appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the endo gia stapler and brought out through the umbilical wound with the endocatch bag.,all hemostasis was further reconfirmed. no leakage of enteral contents was noted. all trocars were removed under direct visualization. the umbilical fascia was closed with interrupted 0 vicryl sutures. the skin was closed with 4-0 monocryl subcuticular stitch and dressed with steri-strips and 4 x 4's. the patient was extubated and taken to the recovery area in stable condition. the patient tolerated the procedure well.

procedure: , elective male sterilization via bilateral vasectomy.,preoperative diagnosis: ,fertile male with completed family.,postoperative diagnosis:, fertile male with completed family.,medications: ,anesthesia is local with conscious sedation.,complications: , none.,blood loss: , minimal.,indications: ,this 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy. i discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed. he has been given prophylactic antibiotics.,procedure note: , once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table. genitalia was shaved and then prepped with betadine scrub and paint solution and were draped sterilely. the procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin. the skin was infiltrated with 2% xylocaine and punctured with a sharp hemostat to identify the vas beneath. the vas was brought out of the incision carefully. a 2-inch segment was isolated, and 1-inch segment was removed. the free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. after securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,attention was now turned to the left side. the vas was grasped and brought up to the level of the skin. the skin was infiltrated with 2% xylocaine and punctured with a sharp hemostat to identify the vas beneath. the vas was brought out of the incision carefully. a 2-inch segment was isolated, and 1-inch segment was removed. the free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves. after securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,bacitracin ointment was applied as well as dry sterile dressing. the patient was awakened and was returned to recovery in satisfactory condition.

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.

preoperative diagnosis: , degenerative arthritis of left knee.,postoperative diagnosis:, degenerative arthritis of left knee.,procedure performed: , nexgen left total knee replacement.,anesthesia: , spinal.,tourniquet time: approximately 66 minutes.,complications:, none.,estimated blood loss: , approximately 50 cc.,components: , a nexgen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a nexgen cruciate retaining size e femoral component, and a size 38 9.5 mm thickness all-poly patella.,brief history:, the patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and adls. she wishes to proceed with arthroplasty at this time.,procedure: ,the patient was taken to the operative suite at abcd general hospital on 09/11/03. she was placed on the operating table. department of anesthesia administered a spinal anesthetic. once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion. an esmarch was applied and a tourniquet was inflated to 325 mmhg on the left thigh. a longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum. a medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle. care was then ensured that the patellar tendon was not violated. the proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line. again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia. the intramedullary canal was then opened using a drill and the anterior sizing guide was then placed. rongeur was used to take out any osteophytes and the size of approximately size e. at this point, the epicondyle axis guide was then inserted and aligned in a proper orientation. the anterior cutting guide was then placed. care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur. after this was performed, this was removed and the distal femoral cutting guide was then placed. the left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken. after the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size e and distal femur. this was placed slightly in lateral position and secured in position with spring tense and head lift tense. once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately. the chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws. after this was performed, the guide was removed and all bony fragments were then removed. attention was then directed to the tibia. the external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position. care was ensured if it is was a varus or valgus and the appropriate. the femur gauge was then used to provide us appropriate amount of bony resection. this was then pinned and secured into place. ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made. this bony portion was then removed and remaining meniscal fragments were removed as well as the acl till adequate exposure was obtained. trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability. the trial components were then removed. the tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment. after it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact. again the trial components were placed back into position. patella button was placed and the tracking was evaluated. they tracked centrally with no touch technique. again, all components were now removed and the knee was then copiously irrigated and suctioned dry. once adequately suctioned dry, the tibial portion was cemented and packed into place. also excess cement was removed. the femoral component was then cemented into position. all excess cement was removed. a size 12 poly was then inserted in trial to provide compression at cement adhered. the patella was then cemented and held into place. all components were held under compression until cement had adequately adhered all excess cement was then removed. the knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice. the knee was again copiously irrigated and suctioned dry. one last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place. after this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components. the knee was once again copiously irrigated, and the tourniquet was deflated. bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained. a drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 ethibond and oversewn with a #1 vicryl. this was flexed and the repair was found held securely. at this point, the knee was again copiously irrigated and suctioned dry. the subcutaneous tissue was closed with #2-0 vicryl, and the skin was approximated with skin staples. sterile dressing with adaptic, 4x4s, abds, and kerlix rolls was then applied. the patient was then transferred back to the gurney in a supine position.,disposition: , the patient tolerated well with no complications, to pacu in satisfactory condition.

exam:, echocardiogram.,indication: , aortic stenosis.,interpretation: , transthoracic echocardiogram was performed of adequate technical quality. left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function. ejection fraction is 60% without any obvious wall motion abnormality. left atrium and right side chambers are of normal size and dimensions. aortic root has normal diameter.,mitral and tricuspid valves are structurally normal except for minimal annular calcification. valvular leaflet excursion is adequate. aortic valve reveals annular calcification. fibrocalcific valve leaflets with decreased excursion. atrial and ventricular septum are intact. pericardium is intact without any effusion. no obvious intracardiac mass or thrombi noted.,doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation. estimated pulmonary pressure of 48. systolic consistent with mild-to-moderate pulmonary hypertension. peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,in summary:,1. concentric hypertrophy of the left ventricle with normal function.,2. doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.

preoperative diagnoses,1. adrenal mass, right sided.,2. umbilical hernia.,postoperative diagnoses,1. adrenal mass, right sided.,2. umbilical hernia.,operation performed: , laparoscopic hand-assisted left adrenalectomy and umbilical hernia repair.,anesthesia: ,general.,clinical note: , this is a 52-year-old inmate with a 5.5 cm diameter nonfunctioning mass in his right adrenal. procedure was explained including risks of infection, bleeding, possibility of transfusion, possibility of further treatments being required. alternative of fully laparoscopic are open surgery or watching the lesion.,description of operation: ,in the right flank-up position, table was flexed. he had a foley catheter in place. incision was made from just above the umbilicus, about 5.5 cm in diameter. the umbilical hernia was taken down. an 11 mm trocar was placed in the midline, superior to the gelport and a 5 mm trocar placed in the midaxillary line below the costal margin. a liver retractor was placed to this.,the colon was reflected medially by incising the white line of toldt. the liver attachments to the adrenal kidney were divided and the liver was reflected superiorly. the vena cava was identified. the main renal vein was identified. coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. coming along the superior pole of the kidney, the tumor was dissected free from top of the kidney with clips and bovie. the harmonic scalpel was utilized superiorly and laterally. posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. specimen was placed in a collection bag, removed intact.,hemostasis was excellent.,the umbilical hernia had been completely taken down. the edges were freshened up. vicryl #1 was utilized to close the incision and 2-0 vicryl was used to close the fascia of the trocar.,skin closed with clips.,he tolerated the procedure well. all sponge and instrument counts were correct. estimated blood loss less than 100 ml.,the patient was awakened, extubated, and returned to recovery room in satisfactory condition.

preoperative diagnosis: , persistent pneumonia, right upper lobe of the lung, possible mass.,postoperative diagnosis: , persistent pneumonia, right upper lobe of the lung, possible mass.,procedure:, bronchoscopy with brush biopsies.,description of procedure: , after obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia. a time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube. first the trachea and the carina had normal appearance. the scope was passed into the left side and the bronchial system was found to be normal. there were scars and mucoid secretions. then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and tb. first, the basal lobes were explored and found to be normal. then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated. then, the bronchi going to the three segments were visualized and no abnormalities or mass were found. brush biopsy was obtained from one of the segments and sent to pathology.,the procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of ambu bagging, he recovered satisfactorily.,at the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,

family history: , her father died at the age of 80 from prostate cancer. her mother died at the age of 67. she did abuse alcohol. she had a brother died at the age of 70 from bone and throat cancer. she has two sons, ages 37 and 38 years old who are healthy. she has two daughters, ages 60 and 58 years old, both with cancer. she describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.,social history: , she is married and has support at home. denies tobacco, alcohol, and illicit drug use.,allergies: , aspirin.,medications: ,the patient does not list any current medications.,past medical history: , hypertension, depression, and osteoporosis.,past surgical history: , she has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of c3 through c7 by dr. l. she is g10, p7, no cesarean sections.,review of systems: , heent: headaches, vision changes, dizziness, and sore throat. gi: difficulty swallowing. musculoskeletal: she is right-handed with joint pain, stiffness, decreased range of motion, and arthritis. respiratory: shortness of breath and cough. cardiac: chest pain and swelling in her feet and ankle. psychiatric: anxiety and depression. urinary: negative and noncontributory. hem-onc: negative and noncontributory. vascular: negative and noncontributory. genital: negative and noncontributory.,physical examination:, on physical exam, she is 5 feet tall and currently weighs 110 pounds; weight one year ago was 145 pounds. bp 138/78, pulse is 64. general: a well-developed, well-nourished female, in no acute distress. heent exam, head is atraumatic and normocephalic. eyes, sclerae are anicteric. teeth, she does have some poor dentition. she does say that she needs some of her teeth pulled on her lower mouth. cranial nerves ii, iii, iv, and vi, vision is intact and visual fields are full to confrontation. eoms are full bilaterally. pupils are equal, round, and reactive to light. cranial nerves v and vii, normal facial sensation and symmetrical facial movements. cranial nerve viii, hearing is intact, although decreased bilaterally right worse than left. cranial nerves ix, x, and xii, tongue protrudes midline and palate elevates symmetrically. cranial nerve xi, strong and symmetrical shoulder shrugs against resistance. cardiac, regular rate and rhythm. chest and lungs are clear bilaterally. skin is warm and dry. normal turgor and texture. no rashes or lesions are noted. general musculoskeletal exam reveals no gross deformity, fasciculations, and atrophy. peripheral vascular, no cyanosis, clubbing, or edema. she does have some tremoring of her bilateral upper arms as she said. strength testing reveals difficulty when testing due to the fact that the patient does have a lot of pain, but she seems to be pretty equal in the bilateral upper extremities with no obvious weakness noted. she is about 4+/5 in the deltoids, biceps, triceps, wrist flexors, wrist extensors, dorsal interossei, and grip strength.,it is much more painful for her on the left. deep tendon reflexes are 2+ bilaterally only at biceps, triceps, and brachioradialis, knees, and ankles. no ankle clonus is elicited. hoffmann's is negative bilaterally. sensation is intact. she ambulates with slow short steps. no spastic gait is noted. she has appropriate station and gait with no assisted devices, although she states that she is supposed to be using a cane. she does not bring one in with her today.,findings: , patient brings in cervical spine x-rays and she has had an mri taken but does not bring that in with her today. she will obtain that and x rays, which showed at cervical plate c3, c4, c5, c6, and c7 anteriorly with some lifting with the most lifted area at the c3 level. no fractures are noted.,assessment: , cervicalgia, cervical radiculopathy, and difficulty swallowing status post cervical fusion c3 through c7 with lifting of the plate.,plan:, we went ahead and obtained an ekg in the office today, which demonstrated normal sinus rhythm. she went ahead and obtained her x-rays and will pick her mri and return to the office for surgical consultation with dr. l first available. she would like the plate removed, so that she can eat and drink better, so that she can proceed with her shoulder surgery. all questions and concerns were addressed with her. warning signs and symptoms were gone over with her. if she should have any further questions, concerns, or complications, she will contact our office immediately; otherwise, we will see her as scheduled. i am quite worried about the pain that she is having in her arms, so i would like to see the mri as well. case was reviewed and discussed with dr. l.

preoperative diagnosis: , soft tissue mass, right foot.,postoperative diagnosis: , soft tissue mass, right foot.,procedure performed: , excision of soft tissue mass, right foot.,history: ,the patient is a 51-year-old female with complaints of soft tissue mass over the dorsum of the right foot. the patient has had previous injections to the site which have caused the mass to decrease in size, however, the mass continues to be present and is irritated and painful with shoes. the patient has requested surgical intervention at this time.,procedure: ,after an iv was instituted by the department of anesthesia, the patient was escorted from the preoperative holding area to the operating room. the patient was then placed on the operating room table in the supine position and a towel was placed around the patient's abdomen and secured her to the table. using copious amounts of webril, a pneumatic ankle tourniquet was applied to her right ankle. using a skin skribe, the area of the soft tissue mass was outlined over the dorsum of her foot. after adequate amount of anesthesia was provided by the department of anesthesia, a local ankle block was given using 10 cc of 4.5 ml of 1% lidocaine plain, 4.5 ml of 0.5% marcaine plain and 1.0 ml of solu-medrol and the foot was scrubbed and prepped in a normal sterile orthopedic manner. following this, the ankle was elevated and esmarch bandage applied to exsanguinate the foot and the ankle tourniquet was inflated to 250 mmhg. the foot was then brought back down to the table using bandage scissors. the stockinette was reflected and the right foot was exposed. using a fresh #10 blade, a curvilinear incision was performed over the dorsum of the right foot. then using a #15 blade, the incision was deepened with care taken to identify and avoid or cauterize any bleeders which were noted. following this, the incision was deepened using a combination of sharp and blunt dissection and the muscle belly of the extensor digitorum brevis muscle was identified. further dissection was then performed in the medial direction in the area of the soft tissue mass. the intermediate dorsal cutaneous nerve was identified and gently retracted laterally. large amounts of adipose tissue were noted medial to the belly of the extensor digitorum brevis muscle. using careful dissection, adipose tissue in this area was removed and saved for pathology. following removal of adipose tissue in this area and identification of no more adipose tissue, attention was directed lateral to the belly of the extensor digitorum brevis muscle, which was also noted to have large amounts of adipose tissue in this area as well. using careful dissection, from the lateral border of the foot as much adipose tissue as possible was removed from this area as well and saved for pathology. there was noted to be no other fluid-filled masses or lesions identifiable in this area then between the slits of the extensor digitorum brevis muscle, careful dissection was performed to examine the underside of the belly of the muscle as well as structures beneath and no abnormal structures were identified here as well. following this, feeling adequately that no other mass remained in the area, the incision was flushed using copious amounts of sterile saline. the wound was then reinspected and all remaining tissues appeared healthy including the subcutaneous tissue. the tendon and muscle belly of the extensor digitorum brevis muscle, the nerves of the intermediate dorsal cutaneous nerve and also the medial dorsal cutaneous nerve which were identified medially, all appeared intact. no deficits were noted. no abnormal appearing tissue was present within the surgical site. following this, the skin edges were reapproximated using #4-0 vicryl deep closure of the subcutaneous layer was performed. then, using #4-0 nylon and simple interrupted suture, the skin was reapproximated and closed with care taken to ensure eversion of the skin edges and good approximation of the borders. the patient was also given 7 cc of 1% lidocaine plain throughout the procedure to augment local anesthesia. following this, the wound was dressed using xeroform gauze and 4x4s and was dressed using two abd pads, dorsal and plantar for compression and using kling, kerlix and coban. the patient then had the ankle tourniquet deflated with a total tourniquet time of 55 minutes at 250 mmhg and immediate hyperemia was noted to digits one through five of the right foot. the patient tolerated the procedure and anesthesia well and was noted to have vascular status intact. the patient was then escorted to the postanesthesia care unit where she was placed in a surgical shoe. the patient was then given postoperative instructions to include ice and elevation to her right foot. the patient was cleared for ambulation as tolerated, but was instructed that with increased ambulation will come increased swelling and pain. the patient will follow up with dr. x in his office on tuesday, 08/26/03 for further follow up. the patient was given prescription for vicoprofen #25 taken one tablet q.4h. p.r.n., moderate to severe pain and also prescription for keflex #20 500 mg tablets to be taken b.i.d. x10 days. the patient was given a number for the emergency room and instructed to return if any sign or symptom of infection should present and the patient was educated as to the nature of these. the patient had no further questions and recovered without any complications in the postanesthesia care unit.

history: , coronary artery disease.,technique and findings: ,calcium scoring and coronary artery cta with cardiac function was performed on siemens dual-source ct scanner with postprocessing on vitrea workstation. patient received oral metoprolol 100 milligrams. 100 ml ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. there is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,cardiac wall motion was within normal limits. left ventricular ejection fraction calculated to be 82%. end-diastolic volume 98 ml, end-systolic volume calculated to be 18 ml.,there is normal coronary artery origins. there is codominance between the right coronary artery and the circumflex artery. there is mild to moderate stenosis of the proximal lad with mixed plaque. mild stenosis mid lad with mixed plaque. no stenosis. distal lad with the distal vessel becoming diminutive in size. right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. once again the distal vessel becomes diminutive in size. circumflex shows mild stenosis due to focal calcified plaque proximally. no stenosis is seen involving the mid or distal circumflex. the distal circumflex also becomes diminutive in size. the left main shows small amount of focal calcified plaque without stenosis. myocardium, pericardium and wall motion was unremarkable as seen.,impression:,1. atherosclerotic coronary artery disease with values as above. there are areas of stenosis most pronounced in the lad with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. consider cardiology consult and further evaluation if clinically indicated.,3. full report was sent to the pacs. report will be mailed to dr. abc.

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.

preoperative diagnoses:, cervical spondylotic myelopathy with cord compression and cervical spondylosis.,postoperative diagnoses:, cervical spondylotic myelopathy with cord compression and cervical spondylosis. in addition to this, he had a large herniated disk at c3-c4 in the midline.,procedure: , anterior cervical discectomy fusion c3-c4 and c4-c5 using operating microscope and the abc titanium plates fixation with bone black bone procedure.,procedure in detail: , the patient placed in the supine position, the neck was prepped and draped in the usual fashion. incision was made in the midline the anterior border of the sternocleidomastoid at the level of c4. skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially. the carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at c4-c5. it appeared that the c5-c6 disk area had fused spontaneously. we then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at c3-c4, c4-c5.,after placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at c3-c4, c4-c5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation. we then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments. this was then removed with 2-mm kerrison rongeur. after we removed the posterior longitudinal ligament, we could see the dura pulsating nicely. we did foraminotomies at c3-c4 as well as c4-c5 as well. after having totally decompressed both the cord as well as the nerve roots of c3-c4, c4-c5, we proceeded to the next step, which was a fusion.,we sized two 8-mm cortical cancellous grafts and after distracting the bone at c3-c4, c4-c5, we gently tapped the grafts into place. the distraction was removed and the grafts were now within. we went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,we then placed a titanium abc plate from c3-c5, secured it with 16-mm titanium screws. x-rays showed good position of the screws end plate.,the next step was to place jackson-pratt drain to the vertebral fascia. meticulous hemostasis was obtained. the wound was closed in layers using 2-0 vicryl for the subcutaneous tissue. steri-strips were used for skin closure. blood loss less than about 200 ml. no complications of the surgery. needle counts, sponge count, and cottonoid count was correct.

preoperative diagnoses,1. herniated disc, c5-c6.,2. cervical spondylosis, c5-c6.,postoperative diagnoses,1. herniated disc, c5-c6.,2. cervical spondylosis, c5-c6.,procedures,1. anterior cervical discectomy with decompression, c5-c6.,2. anterior cervical fusion, c5-c6.,3. anterior cervical instrumentation, c5-c6.,4. allograft c5-c6.,anesthesia: ,general endotracheal.,complications:, none.,patient status: , taken to recovery room in stable condition.,indications: , the patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months. nonoperative measures failed to relieve her symptoms and surgical intervention was requested. we discussed reasonable risks, benefits, and alternatives of various treatment options. continuation of nonoperative care versus the risks associated with surgery were discussed. she understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery. despite these risks, she felt that current symptoms will be best managed operatively.,summary of surgery in detail: , following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite. general anesthetic was administered. the patient was placed in the supine position. all prominences and neurovascular structures were well accommodated. the patient was noted to have pulse in this position. preoperative x-rays revealed appropriate levels for skin incision. ten pound inline traction was placed via gardner-wells tongs and shoulder roll was placed. the patient was then prepped and draped in sterile fashion. standard oblique incision was made over the c6 vertebral body in the proximal nuchal skin crease. subcutaneous tissue was dissected down to the level of the omohyoid which was transected. blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally. this was taken down to the prevertebral fascia which was bluntly split. intraoperative x-ray was taken to ensure proper levels. longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures. inferior spondylosis was removed with high-speed bur. a scalpel and curette was used to remove the disc. decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally. disc herniation was removed from the right posterolateral aspect of the interspace. high-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion. curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura. no further evidence of compression was identified. hemostasis was achieved with thrombin-soaked gelfoam. interspace was then distracted with caspar pin distractions set gently. interspace was then gently retracted with the caspar pin distraction set. an 8-mm allograft was deemed in appropriate fit. this was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit. the graft was stable to pull-out forces. distraction and traction was then removed and anterior cervical instrumentation was completed using a depuy trimline anterior cervical plate with 14-mm self-drilling screws. plate and screws were then locked to the plate. final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft. wounds were copiously irrigated with normal saline. omohyoid was approximated with 3-0 vicryl. running 3-0 vicryl was used to close the platysma. subcuticular monocryl and steri-strips were used to close the skin. a deep drain was placed prior to wound closure. the patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition. there were no intraoperative complications. all needle and sponge counts were correct. intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.

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

diagnoses,1. term pregnancy.,2. possible rupture of membranes, prolonged.,procedure:, induction of vaginal delivery of viable male, apgars 8 and 9.,hospital course:, the patient is a 20-year-old female, gravida 4, para 0, who presented to the office. she had small amount of leaking since last night. on exam, she was positive nitrazine, no ferning was noted. on ultrasound, her afi was about 4.7 cm. because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,she was brought to the hospital and begun on pitocin. once she was in her regular pattern, we ruptured her bag of water; fluid was clear. she went rapidly to completion over the next hour and a half. she then pushed for 2 hours delivering a viable male over an intact perineum in an oa presentation. upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications. the baby was vigorous, moving all extremities. the cord was clamped and cut. the baby was handed off to mom with nurse present. apgars were 8 and 9. placenta was delivered spontaneously, intact. three-vessel cord with no retained placenta. estimated blood loss was about 150 ml. there were no tears.

history of present illness: , this is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on cpap and oxygen to evaluate her for difficulty in initiating and maintaining sleep. she returns today to review results of an inpatient study performed approximately two weeks ago.,in the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,she also takes lasix for lower extremity edema.,the patient reports that she generally initiates sleep on cpap, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",medications: , current medications are as previously noted. changes include reduction in prednisone from 9 to 6 mg by mouth every morning. she continues to take ativan 1 mg every six hours as needed. she takes imipramine 425 mg at bedtime.,her ms contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,findings: , vital signs: blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, sao2 is 88% on room air at rest. chest is clear. extremities show lower extremity pretibial edema with erythema.,laboratories: , an arterial blood gas on room air showed a ph of 7.38, pco2 of 52, and po2 of 57.,cpap compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used. she used it for greater than 4 hours per night on 67% of night surveyed. her estimated apnea/hypopnea index was 3 per hour. her average leak flow was 67 liters per minute.,the patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy. she slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%). sleep stage distribution was relatively normal with 2% stage i, 72% stage ii, 24% stage iii, iv, and 2% stage rem sleep.,there were no periodic limb movements during sleep.,there was evidence of a severe predominantly central sleep apnea during non-rem sleep at 173 episodes per hour and during rem sleep at 77 episodes per hour. oxyhemoglobin saturations during non-rem sleep fluctuated from the baseline of 92% to an average low of 82%. during rem sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,of note, the sleep study was performed on cpap at 10.5 cm of h2o with oxygen at 8 liters per minute.,assessment:,1. obesity hypoventilation syndrome. the patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity. in addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2. severe central sleep apnea, on cpap at 10 cmh2o and supplemental oxygen at 8 liters per minute. the breathing pattern is that of cluster or biot's breathing throughout sleep. the primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3. mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4. hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of v/q mismatch and shunt on that basis.,plans: , my overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep. these will include, (1). decrease in evening doses of ms contin, (2). modest weight loss of approximately 10 to 20 pounds, and (3). instituting automated servo ventilation via nasal mask. with regard to latter, the patient will be returning for a trial of asv to examine its effect on sleep-disordered breathing patterns.,in addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements. i have encouraged the patient to increase her dose of lasix from 100 to 120 mg by mouth every morning as previously prescribed. i have also asked her to add lasix in additional late afternoon to evening dose of lasix at 40 mg by mouth at that time. she was instructed to take between one and two k-tab with her evening dose of lasix (10 to 20 meq).,in addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation. further workup for hypoxemia may include high-resolution ct scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.

findings:,there is a lobulated mass lesion of the epiglottis measuring approximately 22 x 16 x 30 mm (mediolateral x ap x craniocaudal) in size. there is slightly greater involvement on the right side however there is bilateral involvement of the aryepiglottic folds. there is marked enlargement of the bilateral aryepiglottic folds (left greater than right). there is thickening of the glossoepiglottic fold. there is an infiltrative mass like lesion extending into the pre-epiglottic space.,there is no demonstrated effacement of the piriform sinuses. the mass obliterates the right vallecula. the paraglottic spaces are normal. the true and false cords appear normal. normal thyroid, cricoid and arytenoid cartilages.,there is lobulated thickening of the right side of the tongue base, for which invasion of the tongue cannot be excluded. a mri examination would be of benefit for further evaluation of this finding.,there is a 14 x 5 x 12 mm node involving the left submental region (level i).,there is borderline enlargement of the bilateral jugulodigastric nodes (level ii). the left jugulodigastric node,measures 14 x 11 x 8 mm while the right jugulodigastric node measures 15 x 12 x 8 mm.,there is an enlarged second left high deep cervical node measuring 19 x 14 x 15 mm also consistent with a left level ii node, with a probable necrotic center.,there is an enlarged second right high deep cervical node measuring 12 x 10 x 10 mm but no demonstrated central necrosis.,there is an enlarged left mid level deep cervical node measuring 9 x 16 x 6 mm, located inferior to the hyoid bone but cephalad to the cricoid consistent with a level iii node.,there are two enlarged matted nodes involving the right mid level deep cervical chain consistent with a right level iii nodal disease, producing a conglomerate nodal mass measuring approximately 26 x 12 x 10 mm.,there is a left low level deep cervical node lying along the inferior edge of the cricoid cartilage measuring approximately 18 x 11 x 14 mm consistent with left level iv nodal disease.,there is no demonstrated pretracheal, prelaryngeal or superior mediastinal nodes. there is no demonstrated retropharyngeal adenopathy.,there is thickening of the adenoidal pad without a mass lesion of the nasopharynx. the torus tubarius and fossa of rosenmuller appear normal.,impression:,epiglottic mass lesion with probable invasion of the glossoepiglottic fold and pre-epiglottic space with invasion of the bilateral aryepiglottic folds.,lobulated tongue base for which tongue invasion cannot be excluded. an mri may be of benefit for further assessment of this finding.,borderline enlargement of a submental node suggesting level i adenopathy.,bilateral deep cervical nodal disease involving bilateral level ii, level iii and left level iv.

preoperative diagnoses: ,1. fractured and retained lumbar subarachnoid spinal catheter.,2. pseudotumor cerebri (benign intracranial hypertension).,procedures: ,1. l1 laminotomy.,2. microdissection.,3. retrieval of foreign body (retained lumbar spinal catheter).,4. attempted insertion of new external lumbar drain.,5. fluoroscopy.,anesthesia: , general.,history: ,the patient had a lumbar subarachnoid drain placed yesterday. all went well with the surgery. the catheter stopped draining and on pulling back the catheter, it fractured and ct scan showed that the remaining fragment is deep to the lamina. the patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,description of procedure: ,after induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls. her face was resting in a pink foam headrest. extreme care was taken positioning her because she weighs 92 kg. there was a lot of extra padding for her limbs and her limbs were positioned comfortably. the arms were not hyperextended. great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance. a foley catheter was in place. she received iv cipro 400 mg because she is allergic to most antibiotics.,fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked. it was also marked where we would try to insert the new catheter at the l4 or l3 interspinous space.,the patient was then prepped and draped in a sterile manner.,a 7-cm incision was made over the l1 lamina. the incision was carried down through the fascia all the way down to the spinous processes. a self-retaining mccullough retractor was placed. the laminae were quite deep. the microscope was brought in and using the midas rex drill with the am-8 bit and removing some of the spinous process of l1-l2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura. the opening in the bone was 1.5 x 1.5 cm.,occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,under high magnification, the dura was opened with an 11 blade and microscissors. at first, there was a linear incision vertically to the left of midline, and i then needed to make a horizontal incision more towards the right. the upper aspect of the cauda equina was visualized and perhaps the lower end of the conus. microdissection under high magnification did not expose the catheter. the fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,i persisted with intensive microdissection and finally we could see the catheter deep to the nerves and i was able to pull it out with the microforceps.,the wound was irrigated with bacitracin irrigation.,at this point, i then attempted lumbar puncture by making a small incision with an 11 blade in the l4 interspinous space and then later in the l3 interspinous space and attempted to puncture the dural sac with the tuohy needle. dr. y also tried. despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned. it will be done at a later date.,i felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus. the potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and i just did not think it was safe to put in this location.,under high magnification, the dura was closed with #6-0 pds interrupted sutures.,after the dura was closed, a piece of gelfoam was placed over the dura. the paraspinous muscles were closed with 0 vicryl interrupted sutures. the subcutaneous fascia was also closed with 0 vicryl interrupted suture. the subcutaneous layer was closed with #2-0 vicryl interrupted suture and the skin with #4-0 vicryl rapide. the 4-0 vicryl rapide sutures were also used at the lumbar puncture sites to close the skin.,the patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room. the patient tolerated procedure well. no complications. sponge and needle counts correct. blood loss minimal, none replaced. this procedure took 5 hours. this case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.

preoperative diagnoses: , carious teeth #2 and #19 and left mandibular dental abscess.,postoperative diagnoses:, carious teeth #2 and #19 and left mandibular dental abscess.,procedures:, extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,anesthesia: , general, oral endotracheal.,complications: , none.,drains: , penrose 0.25 inch intraoral and vestibule and extraoral.,condition:, stable to pacu.,description of procedure:, patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. in addition, the extraoral area on the left neck was prepped with betadine and draped accordingly. gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 ml of lidocaine 2% with 1:100,000 epinephrine and marcaine 1.7 ml of 0.5% with 1:200,000 epinephrine. an incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible. no purulent drainage was obtained. the 0.25 inch penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture. moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19. the area did not drain any purulent material. the carious tooth #19 was then extracted by elevator and forceps extraction. after the tooth was removed, the 0.25 inch penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture. the tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction. after the extraction, the throat pack was removed. an orogastric tube was then placed by dr. x, and stomach contents were suctioned. the pharynx was then suctioned with the yankauer suction. the patient was awakened, extubated, and taken to the pacu in stable condition.

preoperative diagnosis:, empyema.,postoperative diagnosis: , empyema.,procedure performed:,1. right thoracotomy, total decortication.,2. intraoperative bronchoscopy.,anesthesia: , general.,complications: , none.,estimated blood loss:, 300 cc.,fluids: , 2600 cc iv crystalloid.,urine: , 300 cc intraoperatively.,indications for procedure: ,the patient is a 46-year-old caucasian male who was admitted to abcd hospital since 08/14/03 with acute diagnosis of right pleural effusion. a thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion. on ct scan evaluation, there is evidence of an entrapped right lower lobe with loculations. decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,operative procedure: , the patient was taken to the operative suite and placed in the supine position under general anesthesia per anesthesia department. intraoperative bronchoscopy was performed by dr. y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage. samples were obtained from both the left and the right subbronchiole segments for gram stain cultures and asp evaluation. the right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi. at this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear. bronchoscope was then removed. vital signs remained stable throughout this portion of the procedure. the patient was re-intubated by anesthesia with a double lumen endotracheal tube. at this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion. at this point, the right chest was prepped and draped in the usual sterile fashion. the chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with betadine. the first port was placed through this incision intrathoracically. a bronchoscope was placed for inspection of the intrathoracic cavity. pictures were taken. there is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax. at this point, a second port site anteriorly was placed under direct visualization. with the aid of the thoracoscopic view, a yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid. due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped. due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion. incision was made. the subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space. the chest cavity was entered with the right lung deflated per anesthesia at our request. once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe. with the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand. there was no evidence of gross leakage or bleeding at the conclusion of surgery.,full lung re-expansion was noted upon re-inflation of the lung. two #32 french thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus. the chest tubes were secured in place with #0-silk sutures and placed on pneumovac suction. next, the ribs were reapproximated with five interrupted ctx sutures and latissimus dorsi was then reapproximated with a running #2-0 vicryl suture. next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure. steri-strips were applied along with sterile occlusive dressings. the patient was awakened from anesthesia without difficulty and extubated in the operating room. the chest tubes were maintained on pleur-evac suction for full re-expansion of the lung. the patient was transported to the recovery with vital signs stable. stat portable chest x-ray is pending. the patient will be admitted to the intensive care unit for close monitoring overnight.

diagnosis: , status post brain tumor with removal.,subjective: ,the patient is a 64-year-old female with previous medical history of breast cancer that has metastasized to her lung, liver, spleen, and brain, status post radiation therapy. the patient stated that on 10/24/08 she had a brain tumor removed with subsequent left-sided weakness. the patient was readmitted to abc hospital on 12/05/08 and was found to have massive swelling in the brain and a second surgery was performed to reduce the swelling. the patient remained at the acute rehab at abc until she was discharged home on 01/05/09. the patient did receive skilled speech therapy while in the acute rehab, which focused on higher level cognitive and linguistic skills such as attention, memory, mental flexibility, and improvement of her executive function. the patient also complains of difficulty with word retrieval and slurring of speech. the patient denies any difficulty with swallowing at this time.,objective: ,portions of the cognitive linguistic quick test was administered. an oral mechanism exam was performed. a motor speech protocol was completed.,the cognitive linguistic subtests of recalling personal facts, symbol cancellation, confrontational naming, clock drawing, story retelling, generative naming, design and memory, and completion of mazes was administered.,the patient was 100% accurate with recalling personal facts, completion of the symbol cancellation tasks, and with confrontational naming. she had no difficulty with the clock drawing task; however, she has considerable hand tremors, which makes writing difficult. in the storytelling task, she scored within normal limits. she was also within normal limits for generative naming. she did have difficulty with the design, memory, and mazes subtests. she was unable to complete the second maze during the allotted time. the design generation subtest was also completed. she was able to draw four unique designs, and toward the end of the tasks was no longer able to recall the stated direction.,oral mechanism examination:, the patient has mild left facial droop with decreased nasolabial fold. tongue is at midline, and lingual range of motion and strength are within functional limit. the patient does complain of biting her tongue on occasion, but denied biting the inside of her cheeks. her amrs are judged to be within functional limit. her rate of speech is decreased with a monotonous vocal quality. the decreased rate may be a compensation for decreased word retrieval ability. the patient's speech is judged to be 100% intelligible without background noise.,diagnostic impression: ,the patient has mild cognitive linguistic deficits in the areas of higher level cognitive function seen in mental flexibility, memory, and executive function.,plan of care:, outpatient skilled speech therapy two times a week for four weeks to include cognitive linguistic treatment.,short-term goals (three weeks):,1. the patient will complete deductive reasoning and mental flexibility tasks with greater than 90% accuracy, independently.,2. the patient will complete perspective memory test with 100% accuracy using compensatory strategy.,3. the patient will complete visual perceptual activities, which focus on scanning, flexibility, and problem solving with greater than 90% accuracy with minimal cueing.,4. the patient will listen to and/or read a lengthy narrative and be able to recall at least 6 details after a 15-minute delay, independently.,patient's goal: ,to improve functional independence and cognitive abilities.,long-term goal (four weeks): ,functional cognitive linguistic abilities to improve safety and independence at home and to decrease burden of care on caregiver.,

exam: , chest pa & lateral.,reason for exam: , shortness of breath, evaluate for pneumothorax versus left-sided effusion.,interpretation: ,there has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. the lower lobe appears aerated. there is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. the heart and pulmonary vascularity are within normal limits. left-sided port is seen with groshong tip at the svc/ra junction. no evidence for acute fracture, malalignment, or dislocation.,impression:,1. interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. rest of visualized exam nonacute/stable.,3. left central line appropriately situated and stable.,4. preliminary report was issued at time of dictation. dr. x was called for results.

admission diagnoses: , hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,discharge diagnoses: , hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,procedure: , laparoscopic cholecystectomy.,service: , surgery.,history of present illness:, ms. abc is a 57-year-old woman. she suffers from morbid obesity. she also has diabetes and obstructive sleep apnea. she was evaluated in the bariatric surgical center for placement of a band. during her workup, she was noted to have evidence of cholelithiasis. it was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band. the patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438. she was admitted to the hospital for treatment of her hyperglycemia.,hospital course: , ms. abc was admitted to the hospital. she was seen by dr. a. he put her on an insulin drip. her sugars slowly did come down to normal down to between 115 and 134. on the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. she was noted to be a difficult intubation for the procedure. there were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. she underwent the procedure. she tolerated without difficulty. she was recovered in the postoperative care unit and then returned to the floor. her blood sugar postprocedure was noted to be 233. she was started back on a sliding scale insulin. she continued to do well and was felt to be stable for discharge following the procedure.,discharge instructions: ,to return to the medifast diet. to continue with her blood glucose. she needs to follow up with dr. b, and she will see me next week on friday. we will determine if we will proceed with her lap band at that time. she may shower. she needs to keep her wounds clean and dry. no heavy lifting. no driving on narcotic pain medicines. she needs to continue with her cpap machine and continue to monitor her sugars.

diagnosis: , chronic laryngitis, hoarseness.,history: ,the patient is a 68-year-old male, was referred to medical center's outpatient rehabilitation department for skilled speech therapy secondary to voicing difficulties. the patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene. the patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions. the patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,short-term goals:,1. to be independent with relaxation and stretching exercises and lessac-madsen resonant voice therapy protocol.,2. he also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3. we did not complete his __________ ratio during his last session; so, i am unsure if he had met his short-term goal number 2.,4. to be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation. however, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,long-term goals:,1. the patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2. the patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,the patient is discharged from my services at this time with a home program to continue to promote normal voicing.

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.

preoperative diagnosis:, invasive carcinoma of left breast.,postoperative diagnosis:, invasive carcinoma of left breast.,operation performed:, left modified radical mastectomy.,anesthesia: , general endotracheal.,indication for the procedure: ,the patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. the patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. she is aware of the risks and complications of surgery, and wished to proceed.,description of procedure: ,the patient was taken to the operating room. she underwent general endotracheal anesthetic. the ted stockings and venous compression devices were placed on both lower extremities and they were functioning well. the patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. the recent biopsy site was located in the upper and outer quadrant of left breast. the plain incision was marked along the skin. tissues and the flaps were injected with 0.25% marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. the flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. the dissection was started medially and extended laterally towards the left axilla. the breast was removed and then the axillary contents were dissected out. left axillary vein and artery were identified and preserved as well as the lung _____. the patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. care was taken to avoid injury to any of the above mentioned neurovascular structures. after the tissues were irrigated, we made sure there were no signs of bleeding. hemostasis had been achieved with hemoclips. hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. the subcu was then approximated with interrupted 4-0 vicryl sutures and skin with clips. the drains were sutured to the chest wall with 3-0 nylon sutures. dressing was applied and the procedure was completed. the patient went to the recovery room in stable condition.

discharge summary,summary of treatment planning:,two major problems were identified at the admission of this adolescent:,1.

reason for consultation:, hematuria and urinary retention.,brief history: , the patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia. the patient had hematuria, and unable to void. the patient had a foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed. foley catheter was repositioned 18 coude was used. about over a liter of fluids of urine was obtained with light pink urine, which was irrigated. the bladder and the suprapubic area returned to normal after the foley placement. the patient had some evidence of clots upon irrigation. the patient has had a chest ct, which showed possible atelectasis versus pneumonia.,past medical history: ,coronary artery disease, diabetes, hypertension, hyperlipidemia, parkinson's, and chf.,family history: ,noncontributory.,social history: , married and lives with wife.,habits:, no smoking or drinking.,review of systems: , denies any chest pain, denies any seizure disorder, denies any nausea, vomiting. does have suprapubic tenderness and difficulty voiding. the patient denies any prior history of hematuria, dysuria, burning, or pain.,physical examination:,vital signs: the patient is afebrile. vitals are stable.,general: the patient is a thin gentleman,genitourinary: suprapubic area was distended and bladder was palpated very easily. prostate was 1+. testes are normal.,laboratory data: , the patient's white counts are 20,000. creatinine is normal.,assessment and plan:,1. pneumonia.,2. dehydration.,3. retention.,4. bph.,5. diabetes.,6. hyperlipidemia.,7. parkinson's.,8. congestive heart failure.,about 30 minutes were spent during the procedure and the foley catheter was placed, foley was irrigated and significant amount of clots were obtained. plan is for urine culture, antibiotics. plan is for renal ultrasound to rule out any pathology. the patient will need cystoscopy and evaluation of the prostate. apparently, the patient's psa is 0.45, so the patient is at low to no risk of prostate cancer at this time. continued foley catheter at this point. we will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.

preoperative diagnosis:, large recurrent right pleural effusion.,postoperative diagnosis:, large recurrent right pleural effusion.,procedure:,1. conscious sedation.,2. chest tube talc pleurodesis of the right chest.,indications: , the patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion. chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day. eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,specimens:, none.,estimated blood loss: , zero.,narrative:, after obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation. vital signs were taken. these were stable, so the patient was then given initially 0.5 mg of versed and 2 mg of morphine iv. after a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 ml of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax. she was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped. the patient was given additional 0.5 mg of versed and 0.5 mg of dilaudid iv achieving a state where the patient was comfortable but readily responsive. the patient tolerated the procedure well. she did complain of up to a 7/10 pain, but quickly this was brought under control. the chest tube was unclamped. now, the patient will be left to rest and she will get a chest x-ray in the morning.

history of present illness:, this is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. he has had several falls recently. he apparently had pneumonia 10 days prior to the onset of the symptoms. he took a course of amoxicillin for this. he complained of increased symptoms with more and more difficulty with coordination. he fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. he fell from three to five feet and landed on his back. he began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,he has had mid and low back pain intermittently. he took a 10-day course of cipro believing that he had a uti. he denies, however, any bowel or bladder problems. there is no incontinence and he does not feel that he is having any difficulty voiding.,past surgical history:, he has a history of surgery on the left kidney, when it was "rebuilt." he has had knee surgery, appendectomy and right inguinal hernia repair.,medications:, his only home medications had been cipro and aleve. however, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, starlix and the aspirin.,allergies:, he has no known drug allergies.,social history:, he smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. he is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. he had been a golfer in the past.,past medical history:, he has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,physical examination:,vital signs: blood pressure 156/101, pulse was 88, respirations 18. he is afebrile.,mental status: he is alert.,cranial nerves: his pupils were reactive to light. he had a dense left cataract present. the right disk margin appears sharp. his eye movements were full. the face was symmetric. pain and temperature sensation were intact over both sides of the face. the tongue was midline.,neck: his neck was supple.,musculoskeletal: he has intact strength and normal tone in the upper extremities. he had increased tone in both lower extremities. he had hip flexion of 4/5 on the left. he had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,neurologic: his reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. he withdrew to plantar stimulation on the left, but did not have a babinski response clearly present. he had intact finger-to-nose testing. marked impairment in heel-to-shin testing. he was able to sit unassisted. he stood with assistance, but had a markedly ataxic gait. on sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,cardiovascular: he had no carotid bruits. his heart rhythm was regular.,back: there was no focal back pain present. he did have a slight sensory level at the upper t spine at approximately t3, both anteriorly and posteriorly.,radiologic data:, mri by my view showed essentially unremarkable t spine. the mri of his c spine showed significant spondylosis in the mid and lower c spine with spondylolisthesis at c7-t1. there is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. there is slight enhancement at the mid-portion of the lesion. this appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,laboratory: ,his initial labs were unremarkable.,impression: ,cervical cord lesion at the c7 to t2 level of unclear etiology. consider a transverse myelitis, tumor, contusion or ischemic lesion.,plan:, will check labs including sedimentation rate, mri of the brain, chest x-ray. he will probably need a lumbar puncture. he also appears to have a mild peripheral neuropathy, which i suspect is an independent problem. we will request labs for this.

right lower extremity:, the arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,left lower extremity:, the arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery. ankle brachial index of 0.9.,impression: , mild bilateral lower extremity arterial obstructive disease.,

chief complaint:, this 61-year-old male presents today with recent finding of abnormal serum psa of 16 ng/ml. associated signs and symptoms: associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow. timing (onset/frequency): onset was 6 months ago. patient denies fever and chills and denies flank pain.,allergies: ,patient admits allergies to adhesive tape resulting in severe rash. patient denies an allergy to anesthesia.,medication history:, patient is not currently taking any medications.,past medical history:, childhood illnesses: (+) asthma, cardiovascular hx: (-) angina, renal / urinary hx: (-) kidney problems.,past surgical history:, patient admits past surgical history of appendectomy in 1992.,social history:, patient admits alcohol use, drinking is described as heavy, patient denies illegal drug use, patient denies std history, patient denies tobacco use.,family history:, patient admits a family history of gout attacks associated with father.,review of systems:, unremarkable with exception of chief complaint.,physical exam: ,bp sitting: 120/80 resp: 20 hr: 72 temp: 98.6,the patient is a pleasant, 61-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.,neck: neck is normal and symmetrical, without swelling or tenderness. thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,respiratory: respirations are even without use of accessory muscles and no intercostal retractions noted. breathing is not labored, diaphragmatic, or abdominal. lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,cardiovascular: normal s1 and s2 without murmurs, gallop, rubs or clicks. peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,gastrointestinal: abdominal organs, bladder, kidney: no abnormalities, without masses, tenderness, or rigidity. hernia: absent; no inguinal, femoral, or ventral hernias noted. liver and/or spleen: no abnormalities, tenderness, or masses noted. stool specimen not indicated.,genitourinary: anus and perineum: no abnormalities. no fissures, edema, dimples, or tenderness noted.,scrotum: no abnormalities. no lesions, rash, or sebaceous cyst noted.,epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,urethral meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,penis: no abnormalities; circumcised; no phimosis, peyronie's, condylomata, or lumps noted.,prostate: size 60 gr, rt>lt and firm.,seminal vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,skin/extremities: skin is warm and dry with normal turgor and there is no icterus. no skin rash, subcutaneous nodules, lesions or ulcers observed.,neurological/psychiatric: oriented to person, place and time. mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,test results:, no tests to report at this time.,impression: ,elevated prostate specific antigen (psa).,plan:, cystoscopy in the office.,diagnostic & lab orders:, ordered serum creatinine. urinalysis and c & s ordered using clean-catch specimen. ordered free prostate specific antigen (psa). ordered ultrasound of prostate.,i have discussed the findings of this follow-up evaluation with the patient. the discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. discussed the possibility of a turp surgical procedure; risks, complications, benefits, and alternative measures discussed. there are no activity restrictions . instructed ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. questions answered. if any questions should arise after returning home i have encouraged the patient to feel free to call the office at 327-8850.,prescriptions: , proscar dosage: 5 mg tablet sig: once daily dispense: 30 refills: 0 allow generic: no,patient instructions:, patient completed benign prostatic hypertrophy questionnaire.

preoperative diagnosis: , appendicitis.,postoperative diagnosis:, appendicitis, nonperforated.,procedure performed:, appendectomy.,anesthesia: , general endotracheal.,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 transverse right lower quadrant incision was made directly over the point of maximal tenderness. sharp dissection utilizing bovie electrocautery was used to expose the external oblique fascia. the fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp. the internal oblique fascia was similarly incised and its muscular fibers were similarly spread. the transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident. upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,the cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound. after the appendix was fully visualized, the mesentery was divided between kelly clamps and ligated with 2-0 vicryl ties. the base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix. the base was ligated with 2-0 vicryl tie over the crushed area, and the appendix amputated along the clamp. the stump of the appendix was cauterized and the cecum was returned to the abdomen.,the peritoneum was irrigated with warm sterile saline. the mesoappendix and cecum were examined for hemostasis which was present. the wound was closed in layers using 2-0 vicryl for the peritoneum and 0 vicryl for the internal oblique and external oblique layers. the skin incision was approximated with 4-0 monocryl in a subcuticular fashion. the skin was prepped with benzoin, and steri-strips were applied. a dressing was placed on the wound. 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.

chief complaint:, dark urine and generalized weakness.,history of present illness:,40 year old hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. in addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.,he did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). he was nauseated but denied vomiting. he did admit to intermittent abdominal discomfort which he could not localize. in addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.,past medical history:, dm ii-hba1c unknown,past surgical history:, cholecystectomy without complication,family history:, mother with diabetes and hypertension. father with diabetes. brother with cirrhosis (etiology not documented).,social history:, he was unemployed and denied any alcohol or drug use. he was a prior “mild” smoker, but quit 10 years previous.,medications:, insulin (unknown dosage),allergies:, no known drug allergies.,physical exam:,temperature: 98.2,blood pressure:118/80,heart rate: 95,respiratory rate: 18,gen: middle age latin-american male, jaundice, alert and oriented to person/place/time.,heent: normocephalic, atraumatic. icteric sclerae, pupils equal, round and reactive to light. clear oropharynx.,neck: supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits.,cv: regular rate and rhythm, normal s1 and s2. no murmurs, gallops or rubs,pulm: clear to auscultation bilaterally without rhonchi, rales or wheezes,abd: soft with mild ruq tenderness to deep palpation, murphy’s sign absent. bowel sounds present. hepatomegaly with liver edge 3 cm below costal margin. splenic tip palpable.,rectal: guaiac negative,ext: shotty inguinal lymphadenopathy bilaterally, largest node 2cm,neuro: strength 5/5 throughout, sensation intact, reflexes symmetric. no focal abnormality identified. no asterixis,skin: jaundice, no rash. no petechiae, gynecomastia or spider angiomata.,hospital course:,the patient was admitted to the hospital to begin workup of liver failure. initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. a ct scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. his abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. an us guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. the overall architecture of the liver was noted to be well preserved.,gastroenterology was consulted for egd and ercp. the egd was normal and the ercp showed normal biliary anatomy without evidence of obstruction. in addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. again, pathologic results were insufficient to make a tissue diagnosis.,by the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. he remained jaundice. given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative afb and gms stains and a single noncaseating granuloma.,by his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. surgery performed an open liver biopsy and lymph node resection.,studies (historical):,ct abdomen: multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. the largest node measures 3.5 x 3.0 cm. the liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. the spleen size is at the upper limit of normal. pancreas, adrenal glands and kidneys are within normal limits. visualized portions of the lung parenchyma are grossly normal.,ct neck: no abnormalities noted,ct head: no intracranial abnormalities,ruq us (for biopsy): heterogenous liver with lymphadenopathy.,ercp: no filling defect noted; normal pancreatic duct visualized. normal visualization of the biliary tree, no strictures. normal exam.

preoperative diagnosis: , clinical stage iii squamous cell carcinoma of the vulva.,postoperative diagnosis: , clinical stage iii squamous cell carcinoma of the vulva.,operation performed:, radical vulvectomy (complete), bilateral inguinal lymphadenectomy (superficial and deep).,anesthesia: , general, endotracheal tube.,specimens: , radical vulvectomy, right and left superficial and deep inguinal lymph nodes. ,indications for procedure: , the patient recently presented with a new vaginal nodule. biopsy was obtained and revealed squamous carcinoma. the lesion extended slightly above the hymeneal ring and because of vaginal involvement was classified as a t3/nx/mx on clinical examination. of note, past history is significant for pelvic radiation for cervical cancer many years previously.,findings: , the examination under anesthesia revealed a 1.5 cm nodule of disease extending slightly above the hymeneal ring. there was no palpable lymphadenopathy in either inguinal node region. there were no other nodules, ulcerations, or other lesions. at the completion of the procedure there was no clinical evidence of residual disease.,procedure:, the patient was brought to the operating room with an iv in place. she was placed in the low anterior lithotomy position after adequate anesthesia had been induced. examination under anesthesia was performed with findings as noted, after which she was prepped and draped. the femoral triangles were marked and a 10 cm skin incision was made parallel to the inguinal ligament approximately 3 cm below the ligament. camper's fascia was divided and skin flaps were elevated with sharp dissection and ligation of vessels where necessary. the lymph node bundles were mobilized by incising the loose areolar tissue attachments to the fascia of the rectus abdominis. the fascia around the sartorius muscle was divided and the specimen was reflected from lateral to medial. the cribriform fascia was isolated and dissected with preservation of the femoral nerve. the femoral sheath containing artery and vein was opened and vessels were stripped of their lymphatic attachments. the medial lymph node bundle was isolated, and cloquet's node was clamped, divided, and ligated bilaterally. the saphenous vessels were identified and preserved bilaterally. the inferior margin of the specimen was ligated, divided, and removed. inguinal node sites were irrigated and excellent hemostasis was noted. jackson-pratt drains were placed and camper's fascia was approximated with simple interrupted stitches. the skin was closed with running subcuticular stitches using 4-0 monocryl suture.,attention was turned to the radical vulvectomy specimen. a marking pen was used to outline the margins of resection allowing 15-20 mm of margin on the inferior, lateral, and anterior margins. the medial margin extended into the vagina and was approximately 5-8 mm. the skin was incised and underlying adipose tissue was divided with electrocautery. vascular bundles were isolated, divided, and ligated. after removal of the specimen, additional margin was obtained from the right vaginal side wall adjacent to the tumor site. margins were submitted on the right posterior, middle, and anterior vaginal side walls. after removal of the vaginal margins, the perineum was irrigated with four liters of normal saline and deep tissues were approximated with simple interrupted stitches of 2-0 vicryl suture. the skin was closed with interrupted horizontal mattress stitches using 3-0 vicryl suture. the final sponge, needle, and instrument counts were correct at the completion of the procedure. the patient was then awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.

procedure performed:, cervical epidural steroid injection, c5-6.,assistant:, none.,anesthesia:, local.,details of procedure: , the patient was brought to the operating theater and placed prone onto the radiolucent table. subsequent monitored anesthesia care was administered. the c-arm was brought into the operative field and an ap view of the lumbar spine was obtained with particular attention to the c5-6 level. the neck area was then prepped with betadine solution and draped sterile. a metallic marker was placed over the c5-6 lamina and a skin wheal was raised in the skin. a #20-gauge tuohy needle was then advanced into the spinal canal using 1% xylocaine anesthetic and the depth of penetration to the c5 lamina was determined. the needle was redirected into the interlaminar space and advanced to the previously determined level. a 10 cc syringe was then placed onto the end of the needle and, using an air-negative technique, the needle was advanced into the epidural space. when a free flow of air was produced, a solution of 80 mg depo-medrol, 2 cc of 1% xylocaine injectable, and 5 cc of normal saline was then injected into the epidural space. the tuohy needle was removed. betadine was cleansed from the skin. a bandage was placed over the needle entrance point. the patient was turned supine onto a regular hospital bed and subsequently allowed to be awakened from anesthesia. the patient was taken to the recovery room in stable condition.