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reason for visit: , the patient is a 74-year-old woman who presents for neurological consultation referred by dr. x. she is accompanied to the appointment by her husband and together they give her history.,history of present illness: , the patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. danish is her native language, but she has been in the united states for many many years and speaks fluent english, as does her husband.,with respect to her walking and balance, she states "i think i walk funny." her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. she has difficulty stepping up on to things like a scale because of this imbalance. she does not festinate. her husband has noticed some slowing of her speed. she does not need to use an assistive device. she has occasional difficulty getting in and out of a car. recently she has had more frequent falls. in march of 2007, she fell when she was walking to the bedroom and broke her wrist. since that time, she has not had any emergency room trips, but she has had other falls.,with respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,the patient does not have headaches.,with respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "i do not feel as smart as i used to be." she feels that her thinking has slowed down. her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,the patient has not had trouble with syncope. she has had past episodes of vertigo, but not recently.,past medical history: ,significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea. she has been on ambien, which is no longer been helpful. she has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,family history: , her father died with heart disease in his 60s and her mother died of colon cancer. she has a sister who she believes is probably healthy. she has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. she has two normal vaginal deliveries.,social history: ,she lives with her husband. she is a nonsmoker and no history of drug or alcohol abuse. she does drink two to three drinks daily. she completed 12th grade.,allergies: , codeine and sulfa.,she has a living will and if unable to make decisions for herself, she would want her husband, vilheim to make decisions for her.,medications,: premarin 0.625 mg p.o. q.o.d., aciphex 20 mg p.o. q. daily, toprol 50 mg p.o. q. daily, norvasc 5 mg p.o. q. daily, multivitamin, caltrate plus d, b-complex vitamins, calcium and magnesium, and vitamin c daily.,major findings: , on examination today, this is a pleasant and healthy appearing woman.,vital signs: blood pressure 154/72, heart rate 87, and weight 153 pounds. pain is 0/10.,head: head is normocephalic and atraumatic. head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,spine: spine is straight and nontender. spinous processes are easily palpable. she has very mild kyphosis, but no scoliosis.,skin: there are no neurocutaneous stigmata.,cardiovascular exam: regular rate and rhythm. no carotid bruits. no edema. no murmur. peripheral pulses are good. lungs are clear.,mental status: assessed for recent and remote memory, attention span, concentration, and fund of knowledge. she scored 30/30 on the mmse when attention was tested with either spelling or calculations. she had no difficulty with visual structures.,cranial nerves: pupils are equal. extraocular movements are intact. face is symmetric. tongue and palate are midline. jaw muscles strong. cough is normal. scm and shrug 5 and 5. visual fields intact.,motor exam: normal for bulk, strength, and tone. there was no drift or tremor.,sensory exam: intact for pinprick and proprioception.,coordination: normal for finger-to-nose.,reflexes: are 2+ throughout.,gait: assessed using the tinetti assessment tool. she was fairly quick, but had some unsteadiness and a widened base. she did not need an assistive device. i gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,review of x-rays: , mri was reviewed from june 26, 2008. it shows mild ventriculomegaly with a trace expansion into the temporal horns. the frontal horn span at the level of foramen of munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm. the sylvian aqueduct is patent. there is no pulsation artifact. her corpus callosum is bowed and effaced. she has a couple of small t2 signal abnormalities, but no significant periventricular signal change.,assessment: ,the patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,problems/diagnoses:,1. possible adult hydrocephalus (331.5).,2. mild gait impairment (781.2).,3. mild cognitive slowing (290.0).,plan: , i had a long discussion with the patient her husband.,i think it is possible that the patient is developing symptomatic adult hydrocephalus. at this point, her symptoms are fairly mild. i explained to them the two methods of testing with csf drainage. it is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and i described that test. about 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture. alternatively, i could bring her into the hospital for four days of csf drainage to determine whether she is likely to respond to shunt surgery. this procedure carries a 2% to 3% risk of meningitis. i also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.

reason for consultation: , management of blood pressure.,history of present illness: , the patient is a 38-year-old female admitted following a delivery. the patient had a cesarean section. following this, the patient was treated for her blood pressure. she was sent home and she came back again apparently with uncontrolled blood pressure. she is on multiple medications, unable to control the blood pressure. from cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath. she complains of fatigue and tiredness. the child had some congenital anomaly, was transferred to hospital, where the child has had surgery. the patient is in intensive care unit.,coronary risk factors:, history of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal. no history of established coronary artery disease and family history noncontributory for coronary disease.,family history: , nonsignificant.,surgical history: ,no major surgery except for c-section.,medications:, presently on cardizem and metoprolol were discontinued. started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,allergies: , none.,personal history: , nonsmoker. does not consume alcohol. no history of recreational drug use.,past medical history:, hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,review of systems:,constitutional: no history of fever, rigors, or chills.,heent: no history of cataract, blurry vision, or glaucoma.,cardiovascular: no congestive heart. no arrhythmia.,respiratory: no history of pneumonia or valley fever.,gastrointestinal: no epigastric discomfort, hematemesis, or melena.,urologic: no frequency or urgency.,musculoskeletal: no arthritis or muscle weakness.,skin: nonsignificant.,neurological: no tia. no cva. no seizure disorder.,physical examination:,vital signs: pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,heent: atraumatic and normocephalic.,neck: neck veins are flat.,lungs: clear.,heart: s1 and s2 regular.,abdomen: soft and nontender.,extremities: no edema. pulses palpable.,laboratory data: , ekg shows sinus tachycardia with nonspecific st-t changes. labs were noted. bun and creatinine within normal limits.,impression:,1. preeclampsia, status post delivery with cesarean section with uncontrolled blood pressure.,2. no prior history of cardiac disease except for borderline gestational diabetes mellitus.,recommendations:,1. we will get an echocardiogram for assessment left ventricular function.,2. the patient will start on labetalol and hydralazine to see how see fairs.,3. based on response to medication, we will make further adjustments. discussed with the patient regarding plan of care, fully understands and consents for the same. all the questions answered in detail.

history:, this 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the emergency department in complete urinary obstruction. after catheterization, the patient underwent cystoscopy on 4/13. on 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved. final diagnosis was adenocarcinoma of the prostate. because of his mental status and general debility, the patient's family declined additional treatment.,laboratory:, none,procedures:,cystoscopy: blockage of the urethra by a markedly enlarged prostate.,transurethral resection of prostate: 45 grams of tissue were sent to the pathology department for analysis.,pathology: , well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.

diagnosis:, refractory anemia that is transfusion dependent.,chief complaint: , i needed a blood transfusion.,history: , the patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. he denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. at this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. he reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. he has been placed on b12, oral iron, and procrit. at this time, we are asked to evaluate him for further causes and treatment for his anemia. he denies any constitutional complaints except for fatigue, malaise, and some dyspnea. he has no adenopathy that he reports. no fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,past medical history: ,diabetes.,past surgical history:, hernia repair.,allergies: , he has no allergies.,medications: , listed in the chart and include coumadin, lasix, metformin, folic acid, diltiazem, b12, prevacid, and feosol.,social history: , he is a tobacco user. he does not drink. he lives alone, but has family and social support to look on him.,family history:, negative for blood or cancer disorders according to the patient.,physical examination:,general: he is an elderly gentleman in no acute distress. he is sitting up in bed eating his breakfast. he is alert and oriented and answering questions appropriately.,vital signs: blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. he is 69 inches tall and weighs 174 pounds.,heent: sclerae show mild arcus senilis in the right. left is clear. pupils are equally round and reactive to light. extraocular movements are intact. oropharynx is clear.,neck: supple. trachea is midline. no jugular venous pressure distention is noted. no adenopathy in the cervical, supraclavicular, or axillary areas.,chest: clear.,heart: regular rate and rhythm.,abdomen: soft and nontender. there may be some fullness in the left upper quadrant, although i do not appreciate a true spleen with inspiration.,extremities: no clubbing, but there is some edema, but no cyanosis.,neurologic: noncontributory.,dermatologic: noncontributory.,cardiovascular: noncontributory.,impression: , at this time is refractory anemia, which is transfusion dependent. he is on b12, iron, folic acid, and procrit. there are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. his creatinine was 1. my impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. his creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,recommendations: ,at this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, ldh, b12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. i have discussed the procedure in detail which the patient. i have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. he is willing to proceed with the studies i have described to him. we will order an ultrasound of his abdomen because of the possible fullness of the spleen, and i will probably see him in follow up after this hospitalization.,as always, we greatly appreciate being able to participate in the care of your patient. we appreciate the consultation of the patient.

delivery note: , the patient came in around 0330 hours in the morning on this date 12/30/08 in early labor and from a closed cervix very posterior yesterday; she was 3 cm dilated. membranes ruptured this morning by me with some meconium. an iupc was placed. some pitocin was started because the contractions were very weak. she progressed in labor throughout the day. finally getting the complete at around 1530 hours and began pushing. pushed for about an hour and a half when she was starting to crown. the foley was already removed at some point during the pushing. the epidural was turned down by the anesthesiologist because she was totally numb. she pushed well and brought the head drown crowning, at which time i arrived and setting her up delivery with prepping and draping. she pushed well delivering the head and delee suctioning was carried out on the perineum because of the meconium even though good amount of amnioinfusion throughout the day was completed. with delivery of the head, i could see the perineum tear and after delivery of the baby and doubly clamping of the cord having baby off to rt in attendance. exam revealed a good second-degree tear ascended a little bit up higher in the vagina and a little off to the right side but rectum sphincter were intact, although i cannot see good fascia around the sphincter anteriorly. the placenta separated with some bleeding seen and was assisted expressed and completely intact. uterus firmed up well with iv pit. repair of the tear with 2-0 vicryl stitches and a 3-0 vicryl in a subcuticular like area just above the rectum and the perineum was performed using a little local anesthesia to top up with the epidural. once this was complete, mom and baby doing well. baby was a female infant. apgars 8 and 9.

preoperative diagnosis: , foraminal disc herniation of left l3-l4.,postoperative diagnoses:,1. foraminal disc herniation of left l3-l4.,2. enlarged dorsal root ganglia of the left l3 nerve root.,procedure performed:, transpedicular decompression of the left l3-l4 with discectomy.,anesthesia:, general.,complications: , none.,estimated blood loss: , minimal.,specimen: , none.,history: , this is a 55-year-old female with a four-month history of left thigh pain. an mri of the lumbar spine has demonstrated a mass in the left l3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the l3 nerve root. upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally. there was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal. i was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root. but because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point i was not able to perform this biopsy without prior consent from the patient. so, surgery ended decompressing the l3 foramen and providing a discectomy with idea that we will obtain contrasted mris in the near future and i will discuss the findings with the patient and make further recommendations.,operative procedure: , the patient was taken to or #5 at abcd general hospital in a gurney. department of anesthesia administered general anesthetic. endotracheal intubation followed. the patient received the foley catheter. she was then placed in a prone position on a jackson table. bony prominences were well padded. localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion. a midline incision was made over the l3-l4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of l3. retractors were placed into the wound to retract the musculature. at this point, the pars interarticularis was identified and the facet joint of l2-l3 was identified. a marker was placed over the pedicle of l3 and confirmed radiographically. next, a microscope was brought onto the field. the remainder of the procedure was noted with microscopic visualization. a high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis. at this point, soft tissue was removed with a kerrison rongeur and the nerve root was clearly identified in the foramen. as the disc space of l3-l4 is identified, there is a small prominence of the disc, but not as impressive as i would expect on the mri. a discectomy was performed at this time removing only small portions of the lateral aspect of the disc. next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance. the medial aspect with the axilla of the nerve root appears to be enlarged. the color of the tissue was consistent with a nerve root tissue. there was no identifiable plane and this is a gentle enlargement of the nerve root. there are no circumscribed lesions or masses that can easily be separated from the nerve root. as i described in the initial paragraph, since i was not prepared to perform a biopsy on the nerve and the patient had not been consented, i do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure. so, at this point there is no further decompression. a nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral. the pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially. the wound was then irrigated copiously and suctioned dry. a concoction of duramorph and ______ was then placed over the nerve root for pain control. the retractors were removed at this point. the fascia was reapproximated with #1 vicryl sutures, subcutaneous tissues with #2 vicryl sutures, and steri-strips covering the incision. the patient transferred to the hospital gurney, extubated by anesthesia, and subsequently transferred to postanesthesia care unit in stable condition.

sample address,re: sample patient,dear doctor:,we had the pleasure of seeing abc and his mother in the clinic today. as you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity. he has been having problems with wheezing, cough and shortness of breath over the last several months. you and your partners have treated him aggressively with inhaled steroids and bronchodilator. despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course. ,although there is no smoke exposure there is a significant family history with both abc's father and uncle having problems with asthma as well as his older sister. the parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house. ,on exam today, abc had some scattered rhonchi which cleared with coughing but was otherwise healthy. ,we spent the majority of our 45-minute just reviewing basic principles of asthma management and i believe that abc's mother is fairly well versed in this. i think the most important thing to realize is that abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization. ,i think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days). i have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,thanks so much for allowing us to be involved in his care. ,sincerely,

preoperative diagnosis: , herniated nucleus pulposus c5-c6.,postoperative diagnosis: , herniated nucleus pulposus c5-c6.,procedure:, anterior cervical discectomy fusion c5-c6 followed by instrumentation c5-c6 with titanium dynamic plating system, aesculap. operating microscope was used for both illumination and magnification.,first assistant: , nurse practitioner.,procedure in detail: , the patient was placed in supine position. the neck was prepped and draped in the usual fashion for anterior discectomy and fusion. an incision was made midline to the anterior body of the sternocleidomastoid at c5-c6 level. the skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. trachea and esophagus were retracted medially. after placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at c5 and c6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,we then cleaned out the disc at c5-c6 after incising the annulus fibrosis. we cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. with this having been done, we then turned our attention with the operating microscope to the osteophytes. we drilled off the vertebral osteophytes at c5-c6, as well as the uncovertebral osteophytes. this was removed along with the posterior longitudinal ligament. after we had done this, the dural sac was opposed very nicely and both c6 nerve roots were thoroughly decompressed. the next step after the decompression of the thecal sac and both c6 nerve roots was the fusion. we observed that there was a ____________ in the posterior longitudinal ligament. there was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,the next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. that was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,after we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,we then use the aesculap cervical titanium instrumentation with the 16-mm screws. after securing the c5-c6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a jackson-pratt drain in the prevertebral space brought out through a separate incision. the wound was closed with 2-0 vicryl for subcutaneous tissues and skin was closed with steri-strips. blood loss during the operation was less than 10 ml. no complications of the surgery. needle count, sponge count, and cottonoid count were correct.,

history of present illness: , this is a ** week gestational age ** delivered by ** at ** on **. gestational age was determined by last menstrual period and consistent with ** trimester ultrasound. ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear. the baby was vertex presentation. the baby was dried, stimulated, and bulb suctioned. apgar scores of ** at one minute and ** at five minutes.,past medical history,maternal history:, the mother is a **-year-old, g**, p** female with blood type **. she is rubella immune, hepatitis surface antigen negative, rpr nonreactive, hiv negative. mother was group b strep **. mother's past medical history is **.,prenatal care: , mother began prenatal care in the ** trimester and had at least ** documented prenatal visits. she did not smoke, drink alcohol, or use illicit drugs during pregnancy.,surgical history: , **,medications:, medications taken during this pregnancy were **.,allergies: , **,family history: , **,social history: , **,physical examination,vital signs: temperature **, heart rate **, respiratory rate **. dextrose stick **. ballard score by the rn is ** weeks. birth weight is ** grams, which is the ** percentile for gestational age. length is ** centimeters which is ** percentile for gestational age. head circumference is ** centimeters which is ** percentile for gestational age.,general: **alert, active, nondysmorphic-appearing infant in no acute distress.,heent: anterior fontanelle open and flat. positive bilateral red reflexes.,ears have normal shape and position with no pits or tags. nares patent. palate intact. mucous membranes moist.,neck: full range of motion.,cardiovascular: normal precordium, regular rate and rhythm. no murmurs. normal femoral pulses.,respiratory; clear to auscultation bilaterally. no retractions.,abdomen: soft, nondistended. normal bowel sounds. no hepatosplenomegaly. umbilical stump is clean, dry, and intact.,genitourinary: normal tanner i **. anus patent.,musculoskeletal: negative barlow and ortolani. clavicles intact. spine straight. no sacral dimple or hair tuft. leg lengths grossly symmetric. five fingers on each hand and five toes on each foot.,skin: warm and pink with brisk capillary refill. no jaundice.,neurological: normal tone. normal root, suck, grasp, and moro reflexes. moves all extremities equally.,diagnostic studies,laboratory data:, **,assessment: , full term, appropriate for gestational age **.,plan:,1. routine newborn care.,2. anticipatory guidance.,3. hepatitis b immunization prior to discharge.,

history:, the patient is a 25-year-old gentleman who was seen in the emergency room at children's hospital today. he brought his 3-month-old daughter in for evaluation but also wanted to be evaluated himself because he has had "rib cage pain" for the last few days. he denies any history of trauma. he does have increased pain with laughing. per the patient, he also claims to have an elevated temperature yesterday of 101. apparently, the patient did go to the emergency room at abcd yesterday, but due to the long wait, he left without actually being evaluated and then thought that he might be seen today when he came to children's.,past medical history: , the patient has a medical history significant for "staphylococcus infection" that was being treated with antibiotics for 10 days.,current medications: , he states that he is currently taking no medications.,allergies: ,he is not allergic to any medication.,past surgical history: , he denies any past surgical history.,social history: , the patient apparently has a history of methamphetamine use and cocaine use approximately 1 year ago. he also has a history of marijuana used approximately 1 year ago. he currently states that he is in a rehab program.,family history:, unknown by the patient.,physical examination:,vital signs: temperature is 99.9, blood pressure is 108/65, pulse of 84, respirations are 16.,general: he is alert and appeared to be in no acute distress. he had normal hydration.,heent: his pupils were equal, round, reactive. extraocular muscles intact. he had no erythema or exudate noted in his posterior oropharynx.,neck: supple with full range of motion. no lymphadenopathy noted.,respiratory: he had equal breath sounds bilaterally with no wheezes, rales, or rhonchi and no labored breathing; however, he did occasionally have pain with deep inspiration at the right side of his chest.,cardiovascular: regular rate and rhythm. positive s1, s2. no murmurs, rubs, or gallops noted.,gi: nontender, nondistended with normoactive bowel sounds. no masses noted.,skin: appeared normal except on the left anterior tibial area where the patient had a healing skin lesion. there were no vesicles, erythema or induration noted.,musculoskeletal: nontender with normal range of motion.,neuro/psyche: the patient was alert and oriented x3 with nonfocal neurological exam.,assessment: , this is a 25-year-old male with nonspecific right-sided chest/abdominal pain from an unknown etiology.,plan: , due to the fact that this patient is an adult male, we will transfer him to xyz medical center for further evaluation. i have spoken with xyz medical center dr. x who has accepted the patient for transfer. he was advised that the patient will be coming in a private vehicle due to fact that he is completely stable and appears to be in no acute distress. dr. x was happy to accept the transfer and indicated that the patient should come to the emergency room area with the transport paperwork. the plan was explained in detail to the patient who stated that he understood and would comply. the appropriate paperwork was created and one copy was given to the patient.,condition on discharge: , at the time of discharge, he was stable, vital signs stable, in no acute distress.

procedure: , gastroscopy.,preoperative diagnosis: , gastroesophageal reflux disease.,postoperative diagnosis:, barrett esophagus.,medications: , mac.,procedure: , the olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. the preparation was excellent and all surfaces were well seen. the hypopharynx appeared normal. the esophagus had a normal contour and normal mucosa throughout its distance, but at the distal end, there was a moderate-sized hiatal hernia noted. the ge junction was seen at 40 cm and the hiatus was noted at 44 cm from the incisors. above the ge junction, there were three fingers of columnar epithelium extending cephalad, to a distance of about 2 cm. this appears to be consistent with barrett esophagus. multiple biopsies were taken from numerous areas in this region. there was no active ulceration or inflammation and no stricture. the hiatal hernia sac had normal mucosa except for one small erosion at the hiatus. the gastric body had normal mucosa throughout. numerous small fundic gland polyps were noted, measuring 3 to 5 mm in size with an entirely benign appearance. biopsies were taken from the antrum to rule out helicobacter pylori. a retroflex view of the cardia and fundus confirmed the small hiatal hernia and demonstrated no additional lesions. the scope was passed through the pylorus, which was patent and normal. the mucosa throughout the duodenum in the first, second, and third portions was entirely normal. the scope was withdrawn and the patient was sent to the recovery room. he tolerated the procedure well.,final diagnoses:,1. a short-segment barrett esophagus.,2. hiatal hernia.,3. incidental fundic gland polyps in the gastric body.,4. otherwise, normal upper endoscopy to the transverse duodenum.,recommendations:,1. follow up biopsy report.,2. continue ppi therapy.,3. follow up with dr. x as needed.,4. surveillance endoscopy for barrett in 3 years (if pathology confirms this diagnosis).

chief reason for consultation:, evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,history of present illness:, this 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. this lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. patient does not get any chest pain or choking in the neck or pain in the back. patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,medications:, patient does not take any specific medications.,past history:, the patient underwent hysterectomy in 1986.,family history:, the patient is married, has four children who are doing fine. family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,social history:, the patient smokes one pack of cigarettes per day and takes drinks on social occasions.

chief complaint:, multiple problems, main one is chest pain at night.,history of present illness:, this is a 60-year-old female with multiple problems as numbered below:,1. she reports that she has chest pain at night. this happened last year exactly the same. she went to see dr. murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. she wakes in the middle of the night and reports that she has a pressure. it is mild-to-moderate in the middle of her chest and will stay there as long she lies down. if she gets up, it goes away within 15 minutes. it is currently been gone on for the last week. she denies any fast heartbeats or irregular heartbeats at this time.,2. she has been having stomach pains that started about a month ago. this occurs during the daytime. it has no relationship to foods. it is mild in nature, located in the mid epigastric area. it has been better for one week as well.,3. she continues to have reflux, has noticed that if she stops taking aciphex, then she has symptoms. if she takes her aciphex, she seems that she has the reflux belching, burping, and heartburn under control.,4. she has right flank pain when she lies down. she has had this off and on for four months. it is a dull achy pain. it is mild in nature.,5. she has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. it is not painful.,6. she has had spots in her armpits initially on the right side and then going to the left side. they are not itchy.,7. she is having problems with urgency of urine. when she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. she is wearing a pad now.,8. she is requesting a colonoscopy for screening as well. she is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.,9. she has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. there has been no swelling or redness or trauma to these areas.,review of systems:, she has recently been to the eye doctor. she has noticed some hearing loss gradually. she denies any problems with swallowing. she denies episodes of shortness of breath, although she has had a little bit of chronic cough. she has had normal bowel movements. denies any black or bloody stools, diarrhea, or constipation. denies seeing blood in her urine and has had no urinary problems other than what is stated above. she has had no problems with edema or lower extremity numbness or tingling.,social history:, she works at nursing home. she is a nonsmoker. she is currently trying to lose weight. she is on the diet and has lost several pounds in the last several months. she quit smoking in 1972.,family history: , her father has type i diabetes and heart disease. she has a brother who had heart attack at the age of 52. he is a smoker.,past medical history:, episodic leukopenia and mild irritable bowel syndrome.,current medications:, aciphex 20 mg q.d. and aspirin 81 mg q.d.,allergies:, no known medical allergies.,objective:,vital signs: weight: 142 pounds. blood pressure: 132/78. pulse: 72.,general: this is a well-developed adult female who is awake, alert, and in no acute distress.,heent: her pupils are equally round and reactive to light. conjunctivae are white. tms look normal bilaterally. oropharynx appears to be normal. dentition is excellent.,neck: supple without lymphadenopathy or thyromegaly.,lungs: clear with normal respiratory effort.,heart: regular rhythm and rate without murmur. radial pulses are normal bilaterally.,abdomen: soft, nontender, and nondistended without organomegaly.,extremities: examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the pip joint and dip joint. her armpits are examined. she has what appears to be a tinea versicolor rash present in the armpits bilaterally. she has a lesion on her left shoulder, which is 6 mm in diameter. it has diffuse borders and is slightly red. it has two brown spots in it. in her lower extremities, there is no cyanosis or edema. pulses at the radial and posterior tibial pulses are normal bilaterally. her gait is normal.,psychiatric: her affect is pleasant and positive.,neurological: she is grossly intact. her speech seems to be clear. her coordination of upper and lower extremities is normal.,assessment/plan:,1. chest pain. at this point, because of dr. murphy’s evaluation last year and the symptoms exactly the same, i think this is noncardiac. my intonation is that this is reflux. i am going have her double her aciphex or increase it to b.i.d., and i am going to have her see dr. xyz for possible egd if he thinks that would be appropriate. she is to let me know if her symptoms are getting worse or if she is having any severe episodes.,2. stomach pain, uncertain at this point, but i feel like this is probably related as well to chest pain.,3. suspicious lesions on the left shoulder. we will do a punch biopsy and set her up for an appointment for that.,4. tinea versicolor in the axillary area. i have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.,5. cystocele. we will have her see dr. xyz for further discussion of repair due to her urinary incontinence.,6. history of leukopenia. we will check a cbc.,7. pain in the thumbs, probably arthritic in nature, observe for now.,8. screening. we will have her see dr. xyz for discussion of colon cancer screening.,9. gastroesophageal reflux disease. i have increased aciphex to b.i.d. for now.

xyz, d.c.,60 evergreen place,suite 902,east orange, nj 07018,re:

preoperative diagnosis: , tailor's bunion, right foot.,postoperative diagnosis: , tailor's bunion, right foot.,procedure: , closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot.,anesthesia: , local infiltrate with iv sedation.,indications for surgery: , the patient has had a longstanding history of foot problems. the problem has been progressive in nature. the preoperative discussion with the patient included alternative treatment options, the procedure was explained, and the risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, and the postoperative management were discussed. the patient has been advised, although no guarantee for success could be given, most of the patient have less pain and improved function, all questions were thoroughly answered. the patient requested for surgical repair since the problem has reached a point that interfere with normal daily activity. the purpose of the surgery is to alleviate pain and discomfort.,details of procedure: ,the patient was given 1 g of ancef iv for antibiotic prophylaxis 30 minutes prior to the procedure. the patient was brought to the operating room and placed in the supine position. no tourniquet was utilized. iv sedation was achieved followed by a local anesthetic consisting of approximately 10 ml total in 1:1 mixture of 0.25% marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site. the lower extremity was prepped and draped in the usual sterile manner. balanced anesthesia was obtained.,procedure:, closing wedge osteotomy, fifth metatarsal with internal screw fixation, right foot. a dorsal curvilinear incision was made extending from the base of the proximal phalanx fifth digit to a point 1.5 cm from the base of the fifth metatarsal. care was taken to identify and retract all vital structures and when necessary, vessels were ligated via electrocautery. the extensor tendon was identified and retracted medially. sharp and blunt dissection was carried down through the subcutaneous tissue down to the periosteal layer. a linear periosteal capsular incision was made in line with the skin incision. the capsular tissue and periosteal layer was underscored, free from its underlying osseous attachment, and then reflected to expose the osseous surface. inspection of the fifth metatarsophalangeal joint revealed articular cartilage to be perverse and hypertrophic changes to the lateral and dorsolateral aspect of the fifth metatarsal head. an oscillating saw was utilized to carefully resect the hypertrophic portion of the fifth metatarsal head to a more normal configuration. the both edges were rasped smooth.,attention was then focused on the fifth metatarsal. the periosteal layer proximal to the fifth metatarsal head was underscored, free from its underlying attachment, and then reflected to expose the osseous surface. an excess guide position perpendicular to the weightbearing surface was placed to define apex of the osteotomy.,using an oscillating saw, a vertically placed, wedge-shaped oblique ostomy was made with the apex being proximal, lateral, and the base medial and distal. generous amounts of lateral cortex were preserved for the lateral hinge. the wedge was removed from the surgical field. the fifth metatarsal was placed in the appropriate position and stabilized with a guide pin, which was then countersunk and a 3-0 x 40 mm cannulated cortical screw was placed over the guide pin and secured into position. good purchase was noted at the osteotomy site. inspection revealed satisfactory reduction of the fourth intermetatarsal angle with the fifth metatarsal in good alignment and position. the surgical site was flushed with copious amounts of normal saline irrigation. the periosteal and capsular layers were closed with running sutures of 3-0 vicryl. the subcutaneous tissues were closed with 4-0 vicryl, and the skin edges were closed with 4-0 nylon in a running interrupted fashion. a dressing consisting of adaptic, 4 x 4, confirming bandages, and ace wrap to provide mild compression was applied. the patient tolerated the procedure and anesthesia well and left the operating room to the recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by normal capillary refill time, and all digits were warm and pink.,a walker boot was dispensed and applied. the patient should wear that all the time when standing or walking and be nonweightbearing with crutches and to clear by me.,office visit will be in 4 days. the patient was given prescriptions for keflex 500 mg one p.o. t.i.d. for 10 days and ultram er, #15 one p.o. daily along with written and oral home instructions including a number on which i can be reached 24 hours a day if any problem arises.,after short recuperative period, the patient was discharged home with a vital sign stable in no acute distress.

preoperative diagnoses: , angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and pad.,postoperative diagnoses: , angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and pad. significant coronary artery disease, very severe pad.,procedures performed:,1. right common femoral artery cannulation.,2. conscious sedation using iv versed and iv fentanyl.,3. retrograde bilateral coronary angiography.,4. abdominal aortogram with pelvic runoff.,5. left external iliac angiogram with runoff to the patient's left foot.,6. left external iliac angiogram with runoff to the patient's right leg.,7. right common femoral artery angiogram runoff to the patient's right leg.,procedure in detail:, the patient was taken to the cardiac catheterization laboratory after having a valid consent. he was prepped and draped in the usual sterile fashion.,after local infiltration with 2% xylocaine, the right common femoral artery was entered percutaneously and a 4-french sheath was placed over the artery. the arterial sheath was flushed throughout the procedure.,conscious sedation was obtained using iv versed and iv fentanyl.,with the help of a wholey wire, a 4-french 4-curve judkins right coronary artery catheter was advanced into the ascending aorta. the wire was removed, the catheter was flushed. the catheter was engaged in the left main. injections were performed at the left main in different views. the catheter was then exchanged for an rca catheter, 4-french 4-curve which was advanced into the ascending aorta with the help of a j-wire. the wire was removed, the catheter was flushed. the catheter was engaged in the rca. injections were performed at the rca in different views.,the catheter was then exchanged for a 5-french omniflush catheter, which was advanced into the abdominal aorta with the help of a regular j-wire. the wire was removed. the catheter was flushed. abdominal aortogram was then performed with runoff to the patient's pelvis.,the omniflush catheter was then retracted into the aortic bifurcation. through the omniflush catheter, a glidewire was then advanced distally into the left sfa. the omniflush was then removed. through the wire, a royal flush catheter was then advanced into the left external iliac. the wire was removed. left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed. the catheter was then retracted into the left common iliac. angiograms were performed of the left common iliac with runoff to the patient's left groin. the catheter was then positioned at the level of the right common iliac. angiogram of the right common iliac with runoff to the patient's right leg was then performed. the catheter was then removed with the help of a j-wire. the j-wire was left in the abdominal aorta. hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,the wire was then removed. the arterial sheath was then removed after being flushed. hemostasis was obtained using hand compression.,the patient tolerated the procedure well and had no complications. at the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right pt pulse.,hemodynamic findings:, aortic pressure 140/70.,angiographic findings: , left main with calcification 25% to 40% lesion.,the left main is very short.,lad with calcification 25% to 40% proximal lesion.,d1 has 25% lesion. no in-stent restenosis was noted in d1.,d2 and d3 are very small with luminal irregularities.,circumflex artery was diseased throughout the vessel. the circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,om1 has 25% to 40% lesion. these oms are small with luminal irregularities.,rca has 25% to 50% lesion, distally, the rca has luminal irregularities.,left ventriculography was not done.,abdominal aortogram:, right renal artery with luminal irregularities. left renal artery with luminal irregularities. the abdominal aorta has 25% lesion.,right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,the right external iliac has a proximal 75% lesion.,the distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-french sheath.,the right sfa was visualized, although not very well.,left common iliac with 25% to 50% lesion. left external iliac with 25% to 40% lesion. left common femoral with 25% to 40% lesion. left sfa with 25% lesion. left popliteal with wall luminal irregularities.,three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,conclusions: severe coronary artery disease. very severe peripheral arterial disease.,plan: , because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for cad. we will proceed with revascularization of the right external iliac as well as right common femoral. discontinue tobacco.

chief complaint: ,this 18 year old male presents today with shoulder pain right. location: he indicates the problem location is the right shoulder diffusely. quality: quality of the pain is described by the patient as aching, throbbing and tolerable. patient relates pain on a scale from 0 to 10 as 5/10. severity: the severity has worsened over the past 3 months. timing (onset/frequency): onset was gradual and after pitching a baseball game. modifying factors: patient's condition is aggravated by throwing. he participates with difficulty in basketball. past conservative treatments include nsaid and muscle relaxant medications.,allergies: , no known medical allergies.,medication history:, none.,past medical history: ,childhood illnesses: (+) strep throat (+) mumps (+) chickenpox,past surgical history:, no previous surgeries.,family history:, patient admits a family history of arthritis associated with mother.,social history: , patient denies smoking, alcohol abuse, illicit drug use and stds.,review of systems:,musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in am.,psychiatric: (-) psychiatric or emotional difficulties.,eyes: (-) visual disturbance or change.,neurological: (-) neurological symptoms or problems endocrine: (-) endocrine-related symptoms.,allergic / immunologic: (-) allergic or immunologic symptoms.,ears, nose, mouth, throat: (-) symptoms involving ear, nose, mouth, or throat.,gastrointestinal: (-) gi symptoms.,genitourinary: (-) gu symptoms.,constitutional symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,cardiovascular: (-) cardiovascular problems or chest symptoms.,respiratory: (-)breathing difficulties, respiratory symptoms.,physical exam: bp standing: 116/68 resp: 16 hr: 68 temp: 98.1 height: 5 ft. 11 in. weight: 165 lbs. patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. oriented to person, place and time. right shoulder shows evidence of swelling and tenderness. radial pulses are 2 /4, bilateral. brachial pulses are 2 /4, bilateral.,appearance: normal.,tenderness: anterior - moderate, biceps - none, posterior - moderate and subacromial - moderate right.,range of motion: right shoulder rom shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation. l shoulder normal.,strength: external rotation - fair. internal rotation - poor right.,ac joint: pain with abd and cross-chest - mild right.,rotator cuff: impingement - moderate. painful arc - moderate right.,instability: none.,test & x-ray results:, x-rays of the shoulder were performed. x-ray of right shoulder reveals cuff arthropathy present.,impression: , rotator cuff syndrome, right.,plan: , diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed. i noted that this is a very common condition resulting in significant difficulties with use of the arm. several treatment options and their potential benefits were described. nonsteroidal anti-inflammatories can be helpful but typically are slow acting. cortisone shots can be very effective and are quite safe. often more than one injection may be required. physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength. if these treatments fail to resolve symptoms, an mri or shoulder arthrogram may be required to rule out a rotator cuff tear. injected shoulder joint and with celestone soluspan 1.0 cc . ordered x-rays of shoulder right.,prescriptions:, vioxx dosage: 25 mg tablet sig: tid dispense: 60 refills: 0 allow generic: yes,patient instructions:, patient was instructed to restrict activity. patient was given instructions on rice therapy.

chief complaint:, dog bite to his right lower leg.,history of present illness:, this 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. dog was a german shepherd, it belonged to his brother, and the dog spontaneously attacked him. he sustained a bite to his right lower leg. apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. the dog has given no prior history of any reason to believe he is not a healthy dog. the patient himself developed a puncture wound with a flap injury. the patient has a flap wound also below the puncture wound, a v-shaped flap, which is pointing towards the foot. it appears to be viable. the wound is open about may be roughly a centimeter in the inside of the flap. he was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.,past medical history: ,significant for history of pulmonary fibrosis and atrial fibrillation. he is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.,allergies: ,there are no known allergies.,medications:, include multiple medications that are significant for his lung transplant including prograf, cellcept, prednisone, omeprazole, bactrim which he is on chronically, folic acid, vitamin d, mag-ox, toprol-xl, calcium 500 mg, vitamin b1, centrum silver, verapamil, and digoxin.,family history: , consistent with a sister of his has ovarian cancer and his father had liver cancer. heart disease in the patient's mother and father, and father also has diabetes.,social history:, he is a non-cigarette smoker. he has occasional glass of wine. he is married. he has one biological child and three stepchildren. he works for abcd.,review of systems:, he denies any chest pain. he does admit to exertional shortness of breath. he denies any gi or gu problems. he denies any bleeding disorders.,physical examination,general: presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress.,heent: unremarkable.,neck: supple. there is no mass, adenopathy or bruit.,chest: normal excursion.,lungs: clear to auscultation and percussion.,cor: regular. there is no s3 or s4 gallop. there is no obvious murmur.,abdomen: soft. it is nontender. bowel sounds are present. there is no tenderness.,skin: he does have like a chevron incisional scar across his lower chest and upper abdomen. it appears to be well healed and unremarkable.,genitalia: deferred.,rectal: deferred.,extremities: he has about 1+ pitting edema to both legs and they have been present since the surgery. in the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. the wound is spread apart about may be a centimeter all along that area and it is relatively clean. there was some bleeding when i removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. there were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. the flap appeared to be viable.,neurologic: without focal deficits. the patient is alert and oriented.,impression:, a 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. he is on multiple medications and he is on chronic bactrim. we are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an infectious disease consult. we will see him back in the office early next week to reassess his wound. he is to keep the wound clean with the moist dressing right now. he may shower several times a day.

chief complaint: , newly diagnosed t-cell lymphoma.,history of present illness: , the patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. he was originally treated with antibiotics as a possible tooth abscess. prior to this event, in march of 2010, he was treated for strep throat. the pain at that time was on the right side. about a month ago, he started having night sweats. the patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. all these symptoms were preceded by overwhelming fatigue and exhaustion. he reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. with the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. he also reports occasional headaches with some stabbing and pain in his feet and legs. he also complains of some left groin pain.,past medical history: , significant for hiv diagnosed in 2000. he also had mononucleosis at that time. the patient reports being on anti-hepatitis viral therapy period that was very intense. he took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. he reports no other history of transfusions. he has history of spontaneous pneumothorax. the first episode was 1989 on his right lung. in 1990 he had a slow collapse of the left lung. he reports no other history of pneumothoraces. in 2003, he had shingles. he went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,family history: , notable for his mother who is currently battling non-small cell lung cancer. she is a nonsmoker. his sister is epstein-barr virus positive. the patient's mother also reports that she is epstein-barr virus positive. his maternal grandfather died from complications from melanoma. his mother also has diabetes.,social history: , the patient is single. he currently lives with his mother in house for several both in new york and here in colorado. his mother moved out to colorado eight years ago and he has been out here for seven years. he currently is self employed and does antiquing. he has also worked as nurses' aide and worked in group home for the state of new york for the developmentally delayed. he is homosexual, currently not sexually active. he does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. he does not use alcohol or illicit drugs.,review of systems: , as mentioned above his weight has been fairly stable. although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. he has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. he has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. he has had fevers as well. the rest of his review of systems is negative.,physical exam:,vitals:

preoperative diagnoses: ,1. large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2. cervical spondylosis.,3. cervical stenosis, c5-c6 secondary to above (723.0).,postoperative diagnoses: ,1. large herniated nucleus pulposus, c5-c6 with myelopathy (722.21).,2. cervical spondylosis.,3. cervical stenosis, c5-c6 secondary to above (723.0), with surgical findings confirmed.,procedures: , ,1. anterior cervical discectomy at c5-c6 with spinal cord and spinal canal decompression (63075).,2. anterior interbody fusion at c5-c6, (22554) utilizing bengal cage (22851).,3. anterior instrumentation for stabilization by uniplate construction, c5-c6, (22845); with intraoperative x-ray times two.,anesthesia: , general.,service: , neurosurgery.,operation: ,the patient was brought into the operating room, placed in a supine position where general anesthesia was administered. then the anterior aspect of the neck was prepped and draped in a routine sterile fashion. a linear skin incision was made in the skin fold line from just to the right of the midline to the leading edge of the right sternocleidomastoid muscle and taken sharply to platysma, which was dissected only in a subplatysmal manner bluntly, and with only blunt dissection at the prevertebral space where a localizing intraoperative x-ray was obtained, once self-retaining retractors were placed along the mesial edge of a cauterized longus colli muscle, to protect surrounding tissues throughout the remainder of the case. a prominent anterior osteophyte at c5-c6 was then localized, compared to preoperative studies in the usual fashion intraoperatively, and the osteophyte was excised with a rongeur and bony fragments saved. this allowed for an annulotomy, which was carried out with a #11 blade and discectomy, removed with straight disc forceps portions of the disc, which were sent to pathology for a permanent section. residual osteophytes and disc fragments were removed with 1 and 2-mm micro kerrison rongeurs as necessary as drilling extended into normal cortical and cancellous elements widely laterally as well. a hypertrophied ligament and prominent posterior spurs were excised as well until the dura bulged into the interspace, a sign of a decompressed status. at no time during the case was evidence of csf leakage, and hemostasis was readily achieved with pledgets of gelfoam subsequently removed with copious amounts of antibiotic irrigation. once the decompression was inspected with a double ball dissector and all found to be completely decompressed, and the dura bulged at the interspace, and pulsated, then a bengal cage was filled with the patient's own bone elements and fusion putty and countersunk into position, and was quite tightly applied. further stability was added nonetheless with an appropriate size uniplate, which was placed of appropriate size with appropriate size screws and these were locked into place in the usual manner. the wound was inspected, and irrigated again with antibiotic solution and after further inspection was finally closed in a routine closure in a multiple layer event by first approximation of the platysma with interrupted 3-0 vicryl, and the skin with a subcuticular stitch of 4-0 vicryl, and this was steri-stripped for reinforcement, and a sterile dressing was applied, incorporating a penrose drain, which was carried from the prevertebral space externally to the skin wound and safety pin for security in the usual manner. once the sterile dressing was applied, the patient was taken from the operating room to the recovery area having left in stable condition.,at the conclusion of the case, all instruments, needle, and sponge counts were accurate and correct, and there were no intraoperative complications of any type.

preoperative diagnosis:, stage iv necrotic sacral decubitus.,postoperative diagnosis:, stage iv necrotic sacral decubitus.,procedure performed:, debridement of stage iv necrotic sacral decubitus.,gross findings: , this is a 92-year-old african-american female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm. a long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,operative procedure: ,the patient was properly prepped and draped under local sedation. a 0.25% marcaine was injected circumferentially around the necrotic decubitus. a wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed. all bleeding was cauterized with electrocautery and then a kerlix stack was then placed and a pressure dressing applied. the patient was sent to recovery in satisfactory condition.

preoperative diagnoses:, empyema of the left chest and consolidation of the left lung.,postoperative diagnoses:, empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,operative procedure: , left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,anesthesia:, general.,findings: , the patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two cat scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax. there was also noted to be some mild infiltrates of the right lung. the patient had a 30-year history of cigarette smoking. a chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor. then an abdominal ct scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal ct. the patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed. the patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out. this was suctioned out with the addition of the use of saline ***** in the bronchus. following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,the patient was transferred for continued evaluation and treatment. today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted. these were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus. eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that. the chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract. a second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity. therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout. remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe. there were many pockets of purulent material, which had a gray-white appearance to it. there was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe. the adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time. there seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed. many cultures were taken from several areas. the most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,the apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,procedure and technique:, with the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner. the chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this. therefore, the next incision for thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy. therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space. quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity. specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense. suture ligatures of prolene were required. when the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with prolene sutures.,also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-french foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the foley catheter was removed. the patch was sutured onto the pulmonary artery tear. a similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity. also on the pulmonary artery repair some ***** material was used and also thrombin, gelfoam and surgicel. after reasonably good hemostasis was established pleural cavity was irrigated with saline. as mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung. then two #24 blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk. one was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex. these were later connected to water-seal suction at 40 cm of water with negative pressure.,good hemostasis was observed. sponge count was reported as being correct. intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out. then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib. metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 vicryl. the chest wall was closed with running #1 vicryl and then 2-0 vicryl subcutaneous and staples on the skin. the chest tubes were connected to water-seal drainage with 40 cm of water negative pressure. sterile dressings were applied. the patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen. the patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.

exam:, bilateral carotid ultrasound.,reason for exam: , headache.,technique: ,color grayscale and doppler analysis is employed.,findings:, on the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. at the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis. right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second. the right eca is patent as well with the velocity measurement 0.910 m/second.,the right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis. proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170. the mid internal carotid peak systolic velocity is 0.564 m/second, and mid ica end-diastolic velocity is 0.199 m/second. right ica distal psv 0.580 m/second, right ica distal edv 0.204 m/second. vertebral flow is antegrade on the right at 0.469 m/second.,on the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent. at the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis. see the velocity measurements below:,left carotid eca measurement 0.938 m/second. left common carotid psv 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis. this should be further assessed with cta for more precise measurement. the left proximal ica/psv 0.955 m/second, left proximal ica/edv 0.287 m/second. there is spectral broadening in the proximal aspect of the carotid waveform. the left carotid ica mid psv 0.895, left carotid ica mid edv 0.278 with also spectral broadening present.,the left distal ica/psv 0.561, left distal ica/edv 0.206, again the spectral broadening present. vertebral flow is antegrade at 0.468 m/second.,impression: , the study demonstrates bilateral hard plaque at the bifurcation, left greater than right. there is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup cta is recommended for further assessment.

cc:, rapidly progressive amnesia.,hx: ,this 63 y/o rhm presented with a 1 year history of progressive anterograde amnesia. on presentation he could not remember anything from one minute to the next. he also had some retrograde memory loss, in that he could not remember the names of his grandchildren, but had generally preserved intellect, language, personality, and calculating ability. he underwent extensive evaluation at the mayo clinic and an mri there revealed increased signal on t2 weighted images in the mesiotemporal lobes bilaterally. there was no mass affect. the areas mildly enhanced with gadolinium.,pmh:, 1) cad; mi x 2 (1978 and 1979). 2) pvd; s/p aortic endarterectomy (3/1991). 3)htn. 4)bilateral inguinal hernia repair.,fhx/shx:, mother died of a stroke at age 58. father had cad and htn. the patient quit smoking in 1991, but was a heavy smoker (2-3ppd) for many years. he had been a feed salesman all of his adult life.,ros:, unremarkable. no history of cancer.,exam:, bp 136/75 hr 73 rr12 t36.6,ms: alert but disoriented to person, place, time. he could not remember his birthdate, and continually asked the interviewer what year it was. he could not remember when he married, retired, or his grandchildren's names. he scored 18/30 on the follutein's mmse with severe deficits in orientation and memory. he had moderate difficulty naming. he repeated normally and had no constructional apraxia. judgement remained good.,cn: unremarkable.,motor: full strength throughout with normal muscle tone and bulk.,sensory: intact to lt/pp/prop,coordination: unremarkable.,station: no pronator drift, truncal ataxia or romberg sign.,gait: unremarkable.,reflexes: 3+ throughout with downgoing plantar responses bilaterally.,gen exam: unremarkable.,studies:, mri brain revealed hyperintense t2 signal in the mesiotemporal regions bilaterally, with mild enhancement on the gadolinium scans. mri and ct of the chest and ct of the abdomen showed no evidence of lymphadenopathy or tumor. eeg was normal awake and asleep. antineuronal antibody screening was unremarkable. csf studies were unremarkable and included varicella zoster, herpes zoster, hiv and htlv testing, and cytology. the patient underwent stereotactic brain biopsy at the mayo clinic which showed inflammatory changes, but no organism or etiology was concluded. tft, b12, vdrl, esr, crp, ana, spep and folate studies were unremarkable. neuropsychologic testing revealed severe anterograde memory (verbal and visual)loss, and less severe retrograde memory loss. most other cognitive abilities were well preserved and the findings were consistent with mesiotemporal dysfunction bilaterally.,impression:, limbic encephalitis secondary to cancer of unknown origin.,he was last seen 7/26/96. mmse 20/30 and category fluency 20 . disinhibited affect. mild right grasp reflex. the clinical course was benign and non-progressive, and unusual for such a diagnosis, though not unheard of .

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

reason for consult: ,i was asked to see the patient for c. diff colitis.,history of presenting illness: , briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of c. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea. after admission, she had a ct of the abdomen done, which showed evidence of diffuse colitis and she was started on iv flagyl and also on iv levaquin. she was also placed on iv reglan because of nausea and vomiting. in spite of the above, her white count still continues to be elevated today. on questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,past medical history: , hypertension, hyperlipidemia, recent c. diff colitis, which had resolved based on speaking to dr. x. two weeks ago, he had seen the patient and she was clinically well.,past surgical history: ,noncontributory.,social history: ,no history of smoking, alcohol, or drug use. she lives at home.,home medications: ,she is on atenolol and mevacor.,allergies: no known drug allergies.,review of systems: ,positive for diarrhea and abdominal pain, otherwise main other complaints are weakness. she denies any cough, sputum production, or dysuria at this time. otherwise, a 10-system review is essentially negative.,physical exam:,general: she is awake and alert, currently in no apparent distress.,vital signs: she has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and o2 sat is 98% on 2 l.,heent: pupils are round and reactive to light and accommodation.,chest: clear to auscultation bilaterally.,cardiovascular: s1 and s2 are present. no rales appreciated.,abdomen: she does have tenderness to palpation all over with some mild rebound tenderness also. no guarding noted. bowel sounds present.,extremities: no clubbing, cyanosis, or edema.,ct of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,laboratory: , white blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89. ua on 6/18/2009 showed no evidence of uti. sodium today 130, potassium 2.7, and creatinine 0.4. ast and alt on 6/20/2009 were normal. blood cultures from admission were negative. urine culture on admission was negative. c. diff was positive. stool culture was negative.,assessment:,1. a 72-year-old female with clostridium difficile colitis.,2. diarrhea secondary to above and also could be related reglan, which was discontinued today.,3. leukocytosis secondary to above, mild improvement today though.,4. bilateral pleural effusion by ct of the chest, although could represent thickening.,5. new requirement for oxygen, rule out pneumonia.,6. hypertension.,plan:,1. treat the c. diff aggressively especially given ct appearance and her continued leukocytosis and because of the levaquin, which could have added additional antibiotic pressure, so i will restart the iv flagyl.,2. continue p.o. vancomycin. add florastor to help replenish the gut flora.,3. monitor wbcs closely and follow clinically and if there is any deterioration in her clinical status, i would recommend getting surgical evaluation immediately for surgery if needed.,4. we will check a chest x-ray especially given her new requirement for oxygen.

preoperative diagnoses,1. bowel obstruction.,2. central line fell off.,postoperative diagnoses,1. bowel obstruction.,2. central line fell off.,procedure: , insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,procedure detail: , this lady has a bowel obstruction. she was being fed through a central line, which as per the patient was just put yesterday and this slipped out. at the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion. xylocaine 1% was infiltrated and with the patient in trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty. a seldinger technique was used and a triple-lumen catheter was inserted. there was a good flow through all three ports, which were irrigated with saline prior to connection to the iv solutions.,the catheter was affixed to the skin with sutures and then a dressing was applied.,the postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.

history of present illness: , the patient is an 85-year-old gentleman who has a history of sick sinus syndrome for which he has st. jude permanent pacemaker. pacemaker battery has reached end of life and the patient is dependent on his pacemaker with 100% pacing in the right ventricle. he also has a fairly advanced degree of alzheimer's dementia and is living in an assisted care facility. the patient is unable to make his own health care decision and his daughter abc has medical power of attorney. the patient's dementia has resulted in the patient's having sufficient and chronic anger and his daughter that he refuses to speak with her, refuses to be in a same room with her. for this reason the casa grande regional medical center would obtain surgical and anesthesia consent from the patient's daughter in the fashion keeps the patient and daughter separated. furthermore it is important to note that his degree of dementia has disabled the patient to adequately self monitor his status following surgery for significant changes and to seek appropriate medical care, hence he will be admitted after the pacemaker exchange.,past medical history:,1. sick sinus syndrome, pacemaker dependence with 100% with right ventricular pacing.,2. dementia of alzheimer's disease.,3. gastroesophageal reflux disease.,4. multiple pacemaker implantation and exchanges.,family history: , unobtainable.,social history: , the patient resides full time at abc supervised living facility. he is nonsmoker, nondrinker. he uses wheelchair and moves himself about with his feet. he is independent of activities of daily living and dependent on independent activities of daily living.,allergies to medications: , no known drug allergies.,medications: ,omeprazole 20 mg p.o. daily, furosemide 20 mg p.o. daily, citalopram 20 mg p.o. daily, loratadine 10 mg p.o. p.r.n.,review of systems: , a 10 systems review negative for chest pain, pressure, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, syncope, near-syncopal episodes. negative for recent falls. positive for significant memory loss. all other review of systems is negative.,physical examination:,general: the patient is an 85-year-old gentleman in no acute distress, sitting in the wheelchair.,vital signs: blood pressure is 118/68, pulse is 80 and regular, respirations 16, weight is 200 pounds, oxygen saturation is 90% on room air.,heent: head atraumatic and normocephalic. eyes, pupils are equal and reactive to light and accommodate bilaterally, free from focal lesions. ears, nose, mouth, and throat.,neck: supple. no lymphadenopathy, thyromegaly, or thyroid masses appreciated.,cardiovascular: no jvd or no jugular venous distention. no carotid bruits bilaterally. pacemaker pocket right upper thorax with healed surgical incisions. s1 and s2 are normal. no s3 or s4. there are no murmurs. no heaves or thrills, gout, or gallops. trace edema at dorsum of his feet and ankles. femoral pulses are present without bruits, posterior tibial pulses would be palpable bilaterally.,respiratory: breath sounds are clear but diminished throughout ap diameters expanded. the patient speaks in full sentences. no wheezing, no accessory muscles used for breathing.,gastrointestinal: abdomen is soft and nontender. bowel sounds are active in all 4 quadrants. no palpable pulses. no abdominal bruit is appreciated. no hepatosplenomegaly.,genitourinary: nonfocal.,musculoskeletal: muscle strength in lower extremities is 4/5 bilaterally. upper extremities are 5/5 bilaterally with adequate range of motion.,skin: warm and dry. no obvious rashes, lesions, or ulcerations. ,neurologic: alert, not oriented to place and date. his speech is clear. there are no focal motor or sensory deficits.,psychiatric: talkative, pleasant affect with limited impulse control, severe short-term memory loss.,laboratory data:, blood work dated 12/15/08, white count 4.7, hemoglobin 11.9, hematocrit 33.9, and platelets 115,000. bun 19, creatinine 1.15, glucose 94, potassium 4.5, sodium 140, and calcium 8.6.,diagnostic data:, st. jude pacemaker interrogation dated 11/10/08 shows single chamber pacemaker and vvir mode, implant date 08/2000, 100% paced in right ventricle, battery status is eri. a 12-lead ecg 12/15/08 shows 100% paced rhythm with rate of 80. no q waves at the baseline of atrial fibrillation. last measured ejection fraction 40% 12/08 with no significant decompensation.,impression/plan:,1. sick sinus syndrome.,2. atrial fibrillation.,3. pacemaker dependent.,4. mild cardiomyopathy with ejection fraction 40% and no significant decompensation.,5. pacemaker battery end of life requiring exchange.,6. dementia of alzheimer's disease with short and long term memory dysfunction. the dementia disables the patient from recognizing changes in his health status in knowing if he needed to seek appropriate health care. dementia also renders the patient incapable informed consent, schedule the patient for pacemaker. i explain the patient and reimplantation with any device in the surgical suite. he will require anesthesia assistance for adequate sedation as the patient possesses behavioral risk secondary to his advanced dementia.,7. admit the patient after surgery for postoperative care and monitoring.

exam: , ultrasound examination of the scrotum.,reason for exam: , scrotal pain.,findings: ,duplex and color flow imaging as well as real time gray-scale imaging of the scrotum and testicles was performed. the left testicle measures 5.1 x 2.8 x 3.0 cm. there is no evidence of intratesticular masses. there is normal doppler blood flow. the left epididymis has an unremarkable appearance. there is a trace hydrocele.,the right testicle measures 5.3 x 2.4 x 3.2 cm. the epididymis has normal appearance. there is a trace hydrocele. no intratesticular masses or torsion is identified. there is no significant scrotal wall thickening.,impression: ,trace bilateral hydroceles, which are nonspecific, otherwise unremarkable examination.

preoperative diagnoses,1. left neck pain with left upper extremity radiculopathy.,2. left c6-c7 neuroforaminal stenosis secondary to osteophyte.,postoperative diagnoses,1. left neck pain with left upper extremity radiculopathy.,2. left c6-c7 neuroforaminal stenosis secondary to osteophyte.,operative procedure,1. anterior cervical discectomy with decompression c6-c7.,2. arthrodesis with anterior interbody fusion c6-c7.,3. spinal instrumentation using pioneer 20 mm plate and four 12 x 4.0 mm screws.,4. peek implant 7 mm.,5. allograft using vitoss.,anesthesia: , general endotracheal anesthesia.,findings: , showed osteophyte with a disc complex on the left c6-c7 neural foramen.,fluids: ,1800 ml of crystalloids.,urine output: , no foley catheter.,drains: ,round french 10 jp drain.,specimens,: none.,complications: , none.,estimated blood loss:, 250 ml.,the need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,condition: , extubated with stable vital signs.,indications for the operation:, this is the case of a very pleasant 46-year-old caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped. the patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07. this resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow. she was seen in clinic on 12/11/07 during which time mri of the left shoulder showed no evidence of rotator cuff tear. she did have a previous mri of the cervical spine that did show an osteophyte on the left c6-c7 level. based on this, negative mri of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at c6-c7 level. operation, expected outcome, risks, and benefits were discussed with her. risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma. there is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function. should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma. there is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics. however, the patient may develop deeper-seated infection, which may require return to the operating room. should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft. there is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery. there is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid. there is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve. there is also the risk of pseudoarthrosis and hardware failure. she understood all of these risks and agreed to have the procedure performed.,description of procedure: , the patient brought to the operating room, awake, alert, not in any form of distress. after smooth induction and intubation, a foley catheter was inserted. monitoring leads were placed by premier neurodiagnostics and this revealed normal findings, which remained normal during the entire case. the emgs were silent and there was no evidence of any stimulation. after completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension. the head was supported on a foam doughnut. the right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side. a linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm. the area was then prepped with duraprep.,after sterile drapes were laid out, the incision was made using a scalpel blade #10. wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision. the anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles. dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath. the prevertebral fascia was identified and cut sharply. a localizing x-ray verified the marker to be at the c6-c7 interspace. proceeded to the strip the longus colli muscles off the vertebral body of c6 and c7. self-retaining retractor was then laid out. the annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr. the interior endplate of c6 and superior endplate of c7 was likewise was drilled down together with posteroinferior edge of c6 and the posterior superior edge of c7. there was note of a new osteophyte on the left c6-c7 foramen. this was carefully drilled down. after decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders. they were controlled with slight bipolar coagulation, temporary tamponade with gelfoam. after this was completed, valsalva maneuver showed no evidence of any csf leakage. a 7-mm implant was then tapped into placed after its interior was packed with vitoss. the plate was then applied and secured in place with four 12 x 4.7 mm screws. irrigation of the area was done. a round french 10 jp drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly. the wound was then closed in layers with vicryl 3-0 inverted interrupted sutures as well as vicryl 4-0 subcuticular stitch for the dermis. the wound was reinforced with dermabond. the catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site. c-collar was placed and the patient was transferred to recovery after extubation.

reason for visit: , followup evaluation and management of chronic medical conditions.,history of present illness:, the patient has been doing quite well since he was last seen. he comes in today with his daughter. he has had no symptoms of cad or chf. he had followup with dr. x and she thought he was doing quite well as well. he has had no symptoms of hyperglycemia or hypoglycemia. he has had no falls. his right knee does pain him at times and he is using occasional doses of tylenol for that. he wonders whether he could use a knee brace to help him with that issue as well. his spirits are good. he has had no incontinence. his memory is clear, as is his thinking.,medications:,1. bumex - 2 mg daily.,2. aspirin - 81 mg daily.,3. lisinopril - 40 mg daily.,4. nph insulin - 65 units in the morning and 25 units in the evening.,5. zocor - 80 mg daily.,6. toprol-xl - 200 mg daily.,7. protonix - 40 mg daily.,8. chondroitin/glucosamine - no longer using.,major findings:, weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and o2 saturation 94%. he is afebrile. jvp is normal without hjr. ctap. rrr. s1 and s2. aortic murmur unchanged. abdomen: soft, nt without hsm, normal bs. extremities: no edema on today's examination. awake, alert, attentive, able to get up on to the examination table under his own power. able to get up out of a chair with normal get up and go. bilateral oa changes of the knee.,creatinine 1.7, which was down from 2.3. a1c 7.6 down from 8.5. total cholesterol 192, hdl 37, and triglycerides 487.,assessments:,1. congestive heart failure, stable on current regimen. continue.,2. diabetes type ii, a1c improved with increased doses of nph insulin. doing self-blood glucose monitoring with values in the morning between 100 and 130. continue current regimen. recheck a1c on return.,3. hyperlipidemia, at last visit, he had 3+ protein in his urine. tsh was normal. we will get a 24-hour urine to rule out nephrosis as the cause of his hypertriglyceridemia. in the interim, both dr. x and i have been considering together as to whether the patient should have an agent added to treat his hypertriglyceridemia. specifically we were considering tricor (fenofibrate). given his problems with high cpk values in the past for now, we have decided not to engage in that strategy. we will leave open for the future. check fasting lipid panel today.,4. chronic renal insufficiency, improved with reduction in dose of bumex over time.,5. arthritis, stable. i told the patient he could use extra strength tylenol up to 4 grams a day, but i suggest that he start with a regular dose of 1 to 2 to 3 grams per day. he states he will inch that up slowly. with regard to a brace, he stated he used one in the past and that did not help very much. i worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease. for now he will continue with his cane and walker.,6. health maintenance, flu vaccination today.,plans: , followup in 3 months, by phone sooner as needed.

preoperative diagnosis:, squamous cell carcinoma of right temporal bone/middle ear space.,postoperative diagnosis: , squamous cell carcinoma of right temporal bone/middle ear space.,procedure: , right temporal bone resection; rectus abdominis myocutaneous free flap for reconstruction of skull base defect; right selective neck dissection zones 2 and 3.,anesthesia: , general endotracheal.,description of procedure: ,the patient was brought into the operating room, placed on the table in supine position. general endotracheal anesthesia was obtained in the usual fashion. the neurosurgery team placed the patient in pins and after they positioned the patient the right lateral scalp was prepped with betadine after shave as well as the abdomen. the neck was prepped as well. after this was performed, i made a wide ellipse of the conchal bowl with the bovie and cutting current down through the cartilage of the conchal bowl. a wide postauricular incision well beyond the mastoid tip extending into the right neck was then incised with the bovie with the cutting current and a postauricular skin flap developed leaving the excise conchal bowl in place as the auricle was reflected over anterior to the condyle. after this was performed, i used the bovie to incise the soft tissue around the temporal bone away from the tumor on to the mandible. the condyle was skeletonized so that it could be easily seen. the anterior border of the sternocleidomastoid was dissected out and the spinal accessory nerve was identified and spared. the neck contents to the hyoid were dissected out. the hypoglossal nerve, vagus nerve, and spinal accessory nerve were dissected towards the jugular foramen. the neck contents were removed as a separate specimen. the external carotid artery was identified and tied off as it entered the parotid and tied with a hemoclip distally for the future anastomosis. a large posterior facial vein was identified and likewise clipped for later use. i then used the cutting and diamond burs to incise the skull above the external auditory canal so as to expose the dura underneath this and extended it posteriorly to the sigmoid sinus, dissecting or exposing the dura to the level of the jugular bulb. it became evident there was two tumor extending down the eustachian tube medial to the condyle and therefore i did use the router, i mean the side cutting bur to resect the condyle and the glenoid fossa to expose the medial extent of the eustachian tube. the internal carotid artery was dissected out of the parapharyngeal space into the carotid canal and i drilled carotid canal up until it made. i dissected the vertical segment of the carotid out as it entered the temporal bone until it made us turn to the horizontal portion. once this was dissected out, dr. x entered the procedure for completion of the resection with the craniotomy. for details, please see his operative note.,after dr. x had completed the resection, i then harvested the rectus free flap. a skin paddle was drawn out next to the umbilicus about 4 x 4 cm. the skin paddle was incised with the bovie and down to the anterior rectus sheath. sagittal incisions were made up superiorly and inferiorly to the skin paddle and the anterior rectus sheath dissected out above and below the skin paddle. the sheath was incised to the midline and a small ellipse was made around the fascia to provide blood supply to the overlying skin. the skin paddle was then sutured to the fascia and muscle with interrupted 3-0 vicryl. the anterior rectus sheath was then reflected off the rectus muscle, which was then divided superiorly with the bovie and reflected out of the rectus sheath to an inferior direction. the vascular pedicle could be seen entering the muscle in usual fashion. the muscle was divided inferior to the pedicle and then the pedicle was dissected to the groin to the external iliac artery and vein where it was ligated with two large hemoclips on each vessel. the wound was then packed with saline impregnated sponges. the rectus muscle with attached skin paddle was then transferred into the neck. the inferior epigastric artery was sutured to the end of the external carotid with interrupted 9-0 ethilon with standard microvascular technique. ischemia time was less than 10 minutes. likewise, the inferior epigastric vein was sutured to the end of the posterior facial vein with interrupted 9-0 ethilon as well. there was excellent blood flow through the flap and there were no or any issues with the vascular pedicle throughout the remainder of the case. the wound was irrigated with copious amounts of saline. the eustachian tube was obstructed with bone wax. the muscle was then laid into position with the skin paddle underneath the conchal bowl. i removed most the skin of the conchal bowl de-epithelializing and leaving the fat in place. the wound was closed in layers overlying the muscle, which was secured superiorly to the muscle overlying the temporal skull. the subcutaneous tissues were closed with interrupted 3-0 vicryl. the skin was closed with skin staples. there was small incision made in the postauricular skin where the muscle could be seen and the skin edges were sewn directly to the muscle as to the rectus muscle itself. the skin paddle was closed with interrupted 4-0 prolene to the edges of the conchal bowl.,the abdomen was irrigated with copious amounts of saline and the rectus sheath was closed with #1 prolene with the more running suture, taking care to avoid injury to the posterior rectus sheath by the use of ribbon retractors. the subcutaneous tissues were closed with interrupted 2-0 vicryl and skin was closed with skin staples. the patient was then turned over to the neurosurgery team for awakening after the patient was appropriately awakened. the patient was then transferred to the pacu in stable condition with spontaneous respirations, having tolerated the procedure well.

preoperative diagnoses:,1. hallux valgus, right foot.,2. hallux interphalangeus, right foot.,postoperative diagnoses:,1. hallux valgus, right foot.,2. hallux interphalangeus, right foot.,procedures performed:,1. bunionectomy with distal first metatarsal osteotomy and internal screw fixation, right foot.,2. akin bunionectomy, right toe with internal wire fixation.,anesthesia: , tiva/local.,history: ,this 51-year-old female presents to abcd preoperative holding area after keeping herself npo since mid night for a surgery on her painful bunion through her right foot. the patient has a history of gradual onset of a painful bunion over the past several years. she has tried conservative methods such as wide shoes, accommodative padding on an outpatient basis with dr. x all of which have provided inadequate relief. at this time, she desires attempted surgical correction. the risks versus benefits of the procedure have been discussed with the patient in detail by dr. x and the consent is available on the chart for review.,procedure in detail: , after iv was established by the department of anesthesia, the patient was taken to the operating room via cart and placed on the operative table in supine position and a safety strap was placed across her waist for her protection. copious amounts of webril were applied about the right ankle and a pneumatic ankle tourniquet was placed over the webril.,after adequate iv sedation was administered by the department of anesthesia, a total of 15 cc of 1:1 mixture of 0.5% marcaine plain and 1% lidocaine plain was injected into the foot in a standard mayo block fashion. the foot was elevated off the table. esmarch bandages were used to exsanguinate the right foot. the pneumatic ankle tourniquet was elevated to 250 mmhg. the foot was lowered in the operative field and the sterile stockinet was reflected. a sterile betadine was wiped away with a wet and dry sponge and one toothpick was used to test anesthesia, which was found to be adequate. attention was directed to the first metatarsophalangeal joint, which was found to be contracted, laterally deviated, and had decreased range of motion. a #10 blade was used to make a 4 cm dorsolinear incision. a #15 blade was used to deepen the incision through the subcutaneous layer. all superficial subcutaneous vessels were ligated with electrocautery. next, a linear capsular incision was made down the bone with a #15 blade. the capsule was elevated medially and laterally off the metatarsal head and the metatarsal head was delivered into the wound. a hypertrophic medial eminence was resected with a sagittal saw taking care not to strike the head. the medial plantar aspect of the metatarsal head had some erosive changes and eburnation. next, a 0.45 inch kirschner wire was placed with some access guide slightly plantar flexing the metatarsal taking care not to shorten it. a sagittal saw was used to make a long-arm austin osteotomy in the usual fashion. standard lateral release was also performed as well as a lateral capsulotomy freeing the fibular sesamoid complex.,the capital head was shifted laterally and impacted on the residual metatarsal head. nice correction was achieved and excellent bone to bone contact was achieved. the bone stock was slightly decreased, but adequate. next, a 0.45 inch kirschner wire was used to temporarily fixate the metatarsal capital fragment. a 2.7 x 18 mm synthes cortical screw was thrown using standard ao technique. excellent rigid fixation was achieved. a second 2.0 x 80 mm synthes fully threaded cortical screw was also thrown using standard ao technique at the proximal aspect of the metatarsal head. again, an excellent rigid fixation was obtained and the screws were tight. the temporary fixation was removed. a medial overhanging bone was resected with a sagittal saw. the foot was loaded and the hallux was found to have an interphalangeus deformity present.,a sagittal saw was used to make a proximal cut in approximately 1 cm dorsal to the base of the proximal phalanx, leaving a lateral intact cortical hinge. a distal cut parallel with the nail base was performed and a standard proximal akin osteotomy was done.,after the wedge bone was removed, the saw blade was reinserted and used to tether the osteotomy with counter-pressure used to close down the osteotomy. a #15 drill blade was used to drill two converging holes on the medial aspect of the bone. a #28 gauge monofilament wire was inserted loop to loop and pulled through the bone. the monofilament wire was twisted down and tapped into the distal drill hole. the foot was loaded again and the toe had an excellent cosmetic straight appearance and the range of motion of the first metatarsophalangeal joint was then improved. next, reciprocating rasps were used to smooth all bony surfaces. copious amounts of sterile saline was used to flush the joint. next, a #3-0 vicryl was used to reapproximate the capsular periosteal tissue layer. next, #4-0 vicryl was used to close the subcutaneous layer. #5-0 vicryl was used to the close the subcuticular layer in a running fashion. next, 1 cc of dexamethasone phosphate was then instilled in the joint. the steri-strips were applied followed by standard postoperative dressing consisting of owen silk, 4 x 4s, kling, kerlix, and coban. the pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits. the patient tolerated the above anesthesia and procedure without complications. she was transported via cart to the postanesthesia care unit with vital signs stable and vascular status intact to the right foot. she is to be partial weightbearing with crutches. she is to follow with dr. x. she was given emergency contact numbers and instructions to call if problems arise. she was given prescription for vicodin es #25 one p.o. q.4-6h. p.r.n. pain and naprosyn one p.o. b.i.d. 500 mg. she was discharged in stable condition.

vital signs:, blood pressure *, pulse *, respirations *, temperature *.,general appearance: , alert and in no apparent distress, calm, cooperative, and communicative.,heent:, eyes: eomi. perrla. sclerae nonicteric. no lesions lids, lashes, brows, or conjunctivae noted. funduscopic examination unremarkable. no papilledema, glaucoma, or cataracts. ears: normal set and shape with normal hearing and normal tms. nose and sinus: unremarkable. mouth, tongue, teeth, and throat: negative except for dental work.,neck: , supple and pain free without carotid bruit, jvd, or significant cervical adenopathy. trachea is midline without stridor, shift, or subcutaneous emphysema. thyroid is palpable, nontender, not enlarged, and free of nodularity.,chest: , lungs bilaterally clear to auscultation and percussion.,heart: , s1 and s2. regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop. pmi is nondisplaced. chest wall is unremarkable to inspection and palpation. no axillary or supraclavicular adenopathy detected.,breasts: , normal male breast tissue.,abdomen:, no hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding. no widening of the aortic impulse and intraabdominal bruit on auscultation.,external genitalia: , normal for age. normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,rectal:, negative to 7 cm by gloved digital palpation with hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness. no rectal masses palpated.,extremities: , good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis. nails of the hands and feet, and creases of the palms and soles are unremarkable. good active and passive range of motion of all major joints.,back: , normal to inspection and percussion. negative for spinous process tenderness or cva tenderness. negative straight-leg raising, kernig, and brudzinski signs.,neurologic: , nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function. affect is normal. speech is clear and fluent. thought process is lucid and rational. gait and station are unremarkable.,skin: ,unremarkable for any premalignant or malignant condition with normal changes for age.

history: , neurologic consultation was requested to assess and assist with her seizure medication. the patient is a 3-year 3 months old girl with refractory epilepsy. she had been previously followed by xyz, but has been under the care of the ucsf epilepsy program and recently by dr. y. i reviewed her pertinent previous neurology evaluations at chcc and also interviewed mom.,the patient had seizure breakthrough in august 2007, which requires inpatient admission, thanksgiving and then after that time had seizures every other day, up-to-date early december. she remained seizure-free until 12/25/2007 when she had a breakthrough seizure at home treated with diastat. she presented to our er today with prolonged convulsive seizure despite receiving 20 mg of diastat at home. mom documented 103 temperature at home. in the er, this was 101 to 102 degrees fahrenheit. i reviewed the er notes. at 0754 hours, she was having intermittent generalized tonic-clonic seizures despite receiving a total of 1.5 mg of lorazepam x5. ucsf fellow was contacted. she was given additional fosphenytoin and had a total dose of 15 mg/kg administered. vital weight was 27. seizures apparently had stopped. the valproic acid level obtained at 0835 hours was 79. according to mom, her last dose was at 6 p.m. and she did not receive her morning dose. other labs slightly showed leukocytosis with white blood cell count 21,000 and normal cmp.,previous workup here showed an eeg on 2005, which showed a left posterior focus. mri on june 2007 and january 2005 were within normal limits. mom describes the following seizure types:,1. eye blinking with unresponsiveness.,2. staring off to one side.,3. focal motor activity in one arm and recently generalized tonic seizure.,she also said that she was supposed to see dr. y this friday, but had postponed it to some subsequent time when results of genetic testing would be available. she was being to physicians' care as dr. z had previously being following her last ucsf.,she had failed most of the first and second line anti-epileptic drugs. these include keppra, lamictal, trileptal, phenytoin and phenobarbital. these are elicited to allergies, but she has not had any true allergic reactions to these. actually, it has resulted in an allergic reaction resulting in rash and hypotension.,she also had been treated with clobazam. her best control is with her current regimen of valproic acid and tranxene. other attempts to taper topamax, but this resulted increased seizures. she also has oligohidrosis during this summertime.,current medications: , include diastat 20 mg; topamax 25 mg b.i.d., which is 3.3 per kilo per day; tranxene 15 mg b.i.d.; depakote 125 mg t.i.d., which is 25 per kilo per day.,physical examination:,vital signs: weight 15 kg.,general: the patient was awake, she appeared sedated and postictal.,neck: supple.,neurological: she had a few brief myoclonic jerks of her legs during drowsiness, but otherwise no overt seizure, no seizure activity nor involuntary movements were observed.,she was able to follow commands such as when i request that she gave mom a kiss. she acknowledged her doll. left fundus is sharp. she resisted the rest of the exam. there was no obvious lateralized findings.,assessment:, status epilepticus resolved. triggered by a febrile illness, possibly viral. refractory remote symptomatic partial epilepsy.,impression: , i discussed the maximizing depakote to mom and she concurred. i recommend increasing her maintenance dose to one in the morning, one in the day, and two at bedtime. for today, she did give an iv depacon 250 mg and the above dosage can be continued iv until she is taking p.o. dr. x agreed with the changes and orders were written for this. she can continue her current doses of topamax and tranxene. this can be given by ng if needed. topamax can be potentially increased to 25 mg in the morning and 50 mg at night. i will be available as needed during the rest of her hospitalization. mom will call contact dr. y an update him about the recent changes.

preprocedure diagnosis:, change in bowel function.,postprocedure diagnosis:, proctosigmoiditis.,procedure performed:, colonoscopy with biopsy.,anesthesia: , iv sedation.,postprocedure condition: , stable. ,indications:, the patient is a 33-year-old with a recent change in bowel function and hematochezia. he is here for colonoscopy. he understands the risks and wishes to proceed. ,procedure: , the patient was brought to the endoscopy suite where he was placed in left lateral sims position, underwent iv sedation. digital rectal examination was performed, which showed no masses, and a boggy prostate. the colonoscope was placed in the rectum and advanced, under direct vision, to the cecum. in the rectum and sigmoid, there were ulcerations, edema, mucosal abnormalities, and loss of vascular pattern consistent with proctosigmoiditis. multiple random biopsies were taken of the left and right colon to see if this was in fact pan colitis.,recommendations: , follow up with me in 2 weeks and we will begin canasa suppositories.

as you know, the patient is a 50-year-old right-handed caucasian female, who works as an independent contractor and as a human resources consultant.,her neurological history first begins in december of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk. she had hmo insurance at that time and saw a neurologist, whose name she does not recall. she thinks that she underwent mri scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests. she was told that all the tests were normal and no diagnosis was made.,the slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved. she also began to note that she would fatigue after very prolonged walking.,in about 1993, she developed bladder urgency and frequency along with some nocturia. she saw a urologist and underwent urodynamic testing. she was diagnosed as having "overactive bladder", but the cause of this was never determined. she was treated with medications, possibly ditropan, without much benefit. she also developed a dry mouth from the medication and so she discontinued it.,also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles. apparently, the swelling was not visible by others. she saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established. she saw at least two rheumatologists on several occasions and blood tests were all normal. no clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,however, over time she noted that the symptoms in her legs seemed to worsen somewhat. she states from time-to-time she could "barely walk". she felt as if her balance is impaired and she felt as if she were "walking on stilts". she tried arch supports from a podiatrist without any benefit. she began to tire more easily when walking.,in 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,in the fall of 2002, she was seen by dr. x. he ordered an mri scan of her brain and lumbar spine. he also did some sort of nerve testing and possibly visual evoked response testing. after reviewing everything, he diagnosed multiple sclerosis. however, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to dr. y, in january of 2003. dr. y confirmed the diagnosis of multiple sclerosis.,the patient then returned to dr. x and was started on avonex. she continued on it for about six months. however, it made her feel much more stiff and delayed and so she finally stopped it. she also recalled being tried on baclofen by dr. x, but again it did not benefit her and made her feel slightly dizzy. so, she discontinued it also.,at that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,in december 2004 and extending up to february 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities. she began to have to use a cane. she was seen in neurological consultation by dr. z. she was treated with a medrol dosepak. her spasticity and swelling seemed to improve dramatically. however, within about two weeks symptoms were back to baseline.,she was then treated with intravenous solu-medrol 500 mg daily for five days followed by a prednisone or medrol taper (july 2005). this seemed to be less helpful than the oral steroids, but was partially beneficial. however, it wore off once again.,a repeat mri scan of the brain in april 2005 was said to "look better". she was started on zanaflex for her lower extremity spasticity without benefit.,finally six days ago, she was restarted on oral prednisone 10 mg tablets. she takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs. she continues on the prednisone in the same dosage for relief of the spasticity.,she has not been on any other immunomodulatory agents.,the patient does note some complaints of mild heat sensitivity and mild easy fatigability. there is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,past medical history: , essentially noncontributory.,allergies:, the patient is allergic to lobster and vicodin. she feels that she is probably allergic to iodine.,social history:, she does not smoke. she takes one glass of wine per day.,past surgical history: , she has not had any prior surgeries. her general health has been excellent except for the above-indicated problems.,review of outside radiological studies:, the patient brought with her today mri scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-tesla magnet. there are numerous t2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum. there appear to be dawson's fingers. the mri of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,also available are the mri scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-tesla magnet on 04/22/05. the mri of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,however, the quality of the newer scan is only 0.35-tesla and is suboptimal. visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord. it is difficult to be certain that there are no intra-axial lesions, but i could not clearly see one.,physical examination:,vital signs: blood pressure 151/88, pulse 92, temperature 99.5ºf, and weight 124 lb (dressed).,general: well-developed, well-nourished female in no acute distress.,head: normocephalic, without evidence of trauma or bruits.,neck: supple, with full range of motion. no spasm or tenderness. carotid pulsations are of normal volume and contour bilaterally without bruits. no thyromegaly or adenopathy.,extremities: no clubbing, cyanosis, edema, or deformity. range of motion full throughout.,neurological examination:,mental status: awake, alert, oriented to time, place, and person; appropriate. recent and remote memory intact. no evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,cranial nerves,:,ii: visual fields full to confrontation. fundi benign.,iii, iv, vi: extraocular movements full throughout, without nystagmus. no ptosis. pupils equal, round and react briskly to light and accommodation.,v: normal sensation to light touch and pinprick bilaterally. corneal reflexes equal bilaterally. motor function normal.,vii: no facial asymmetry.,viii: hears finger rub bilaterally. weber and rinne tests normal.,ix & x: palate elevates symmetrically bilaterally with phonation. gag reflex equal bilaterally.,xi: sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,xii: tongue midline without atrophy or fasciculations. rapid alternating movements normal. no dysarthria.,motor: tone, bulk, and strength are normal in both upper extremities. in the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left. there are bilateral achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,strength in the lower extremities is rated as follows on a 5-point scale (right/left): iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5. there are no tremors, fasciculations or abnormal involuntary movements.

reason for visit:, the patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by dr. x.,history of present illness: , the patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. it was felt to be stage 2. it was not n-myc amplified and had favorable shimada histology. in followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable shimada histology. he is now being treated with chemotherapy per protocol p9641 and not on study. he last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. he received g-csf daily after his chemotherapy due to neutropenia that delayed his second cycle. in the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. he is not acted ill or had any fevers. he has had somewhat diminished appetite, but it seems to be improving now. he is peeing and pooping normally and has not had any diarrhea. he did not have any appreciated nausea or vomiting. he has been restarted on fluconazole due to having redeveloped thrush recently.,review of systems: , the following systems reviewed and negative per pathology except as noted above. eyes, ears, throat, cardiovascular, gi, genitourinary, musculoskeletal skin, and neurologic., past medical history:, reviewed as above and otherwise unchanged.,family history:, reviewed and unchanged.,social history: , the patient's parents continued to undergo a separation and divorce. the patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,medications: ,1. bactrim 32 mg by mouth twice a day on friday, saturday, and sunday.,2. g-csf 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3. fluconazole 37.5 mg daily.,4. zofran 1.5 mg every 6 hours as needed for nausea.,allergies: , no known drug allergies.,findings: , a detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm. vital signs: temperature is 35.3 degrees celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmhg. eyes: conjunctivae are clear, nonicteric. pupils are equally round and reactive to light. extraocular muscle movements appear intact with no strabismus. ears: tms are clear bilaterally. oral mucosa: no thrush is appreciated. no mucosal ulcerations or erythema. chest: port-a-cath is nonerythematous and nontender to vp access port. respiratory: good aeration, clear to auscultation bilaterally. cardiovascular: regular rate, normal s1 and s2, no murmurs appreciated. abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses. skin: no rashes. neurologic: the patient walks without assistance, frequently falls on his bottom.,laboratory studies: , cbc and comprehensive metabolic panel were obtained and they are significant for ast 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with anc 2974. medical tests none. radiologic studies are none.,assessment: , this patient's disease is life threatening, currently causing moderately severe side effects.,problems diagnoses: ,1. neuroblastoma of the right adrenal gland with favorable shimada histology.,2. history of stage 2 left adrenal neuroblastoma, status post gross total resection.,3. immunosuppression.,4. mucosal candidiasis.,5. resolving neutropenia.,procedures and immunizations:, none.,plans: ,1. neuroblastoma. the patient will return to the pediatric oncology clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy. i will plan for restaging with ct of the abdomen prior to the cycle.,2. immunosuppression. the patient will continue on his bactrim twice a day on thursday, friday, and saturday. additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3. mucosal candidiasis. we will continue fluconazole for thrush. i am pleased that the clinical evidence of disease appears to have resolved. for resolving neutropenia, i advised gregory's mother about it is okay to discontinue the g-csf at this time. we will plan for him to resume g-csf after his next chemotherapy and prescription has been sent to the patient's pharmacy.,pediatric oncology attending: , i have reviewed the history of the patient. this is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of pog-9641 due to his prior history of neutropenia, he has been on g-csf. his anc is nicely recovered. he will have a restaging ct prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07. he continues on fluconazole for recent history of thrush. plans are otherwise documented above.

preoperative diagnosis: , acute lymphocytic leukemia in remission.,postoperative diagnosis: , acute lymphocytic leukemia in remission.,operation performed: ,removal of venous port.,anesthesia: , general.,indications: , this 9-year-old young lady presented with all in orange county and had a port placed at that time. she subsequently has now undergone chemotherapy here and is now off therapy. she no longer needs her venous port so, comes to the operating room today for its removal.,operative procedure: , after the induction of general anesthetic, the exit site was prepped and draped in usual manner. the previous incision was opened by excising the old scar. the port pocket was then opened and the port was removed from the pocket. there was a resistance to the catheter being removed and so therefore, we began following the catheter along its path opening the tract until finally the catheter seemed to come free and could be pulled out without difficulty. the port pocket was then closed using a #3-0 vicryl in subcutaneous tissue, #5-0 subcuticular monocryl in the skin. sterile dressing was applied. young lady was awakened and taken to the recovery room in satisfactory condition.

clinical indication: ,normal stress test.,procedures performed:,1. left heart cath.,2. selective coronary angiography.,3. lv gram.,4. right femoral arteriogram.,5. mynx closure device.,procedure in detail: , the patient was explained about all the risks, benefits, and alternatives of this procedure. the patient agreed to proceed and informed consent was signed.,both groins were prepped and draped in the usual sterile fashion. after local anesthesia with 2% lidocaine, a 6-french sheath was inserted in the right femoral artery. left and right coronary angiography was performed using 6-french jl4 and 6-french 3drc catheters. then, lv gram was performed using 6-french pigtail catheter. post lv gram, lv-to-aortic gradient was obtained. then, the right femoral arteriogram was performed. then, the mynx closure device was used for hemostasis. there were no complications.,hemodynamics: , lvedp was 9. there was no lv-to-aortic gradient.,coronary angiography:,1. left main is normal. it bifurcates into lad and left circumflex.,2. proximal lad at the origin of big diagonal, there is 50% to 60% calcified lesion present. rest of the lad free of disease.,3. left circumflex is a large vessel and with minor plaque.,4. right coronary is dominant and also has proximal 40% stenosis.,summary:,1. nonobstructive coronary artery disease, lad proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2. rca has 40% proximal stenosis.,3. normal lv systolic function with lv ejection fraction of 60%.,plan: , we will treat with medical therapy. if the patient becomes symptomatic, we will repeat stress test. if there is ischemic event, the patient will need surgery for the lad lesion. for the time being, we will continue with the medical therapy.,

preoperative diagnoses:,1. right shoulder rotator cuff tear.,2. glenohumeral rotator cuff arthroscopy.,3. degenerative joint disease.,postoperative diagnoses:,1. right shoulder rotator cuff tear.,2. glenohumeral rotator cuff arthroscopy.,3. degenerative joint disease.,procedure performed: ,right shoulder hemiarthroplasty.,anesthesia: , general.,estimated blood loss: , approximately 125 cc.,complications:, none.,components: , a depuy 10 mm global shoulder system stem was used cemented and a depuy 44 x 21 mm articulating head was used.,brief history: ,the patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,procedure: , the patient was taken to the operative suite, placed on the operative field. department of anesthesia administered general anesthetic. once adequately sedated, the patient was placed in the beach chair position. care was ensured that she was well positioned, adequately secured and padded. at this point, the right upper extremity was then prepped and draped in the usual sterile fashion. a deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,at this point, blunt dissection with mayo scissors was used to come to the overlying subscapular tendon and bursal tissue. any perforating bleeders were cauterized with bovie to obtain hemostasis. once the bursa was seen, it was removed with a rongeur and subscapular tendon could be easily visualized. at this point, the rotator cuff in the subacromial region was evaluated. there was noted to be a large rotator cuff, which was irreparable. there was eburnated bone on the greater tuberosity noted. the articular surface could be visualized. the biceps tendon was intact. there was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface. the under surface of the acromion, it was felt there was mild ware on this as well. at this point, the subscapular tendon was then taken off using bovie cautery and metzenbaum scissors that was tied with metzenbaum suture. it was separated from the capsule to have a two layered repair at closure. the capsule was also reflected posterior. at this point, the glenoid surface could be easily visualized. it was evaluated and had good cartilage contact and appeared to be intact. the humeral head was evaluated. there was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head. at this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head. the arm was adequately positioned. an oscillating saw was used to make the head articular cut. this was done at the margin of the articular surface with the anatomic neck. this was taken down to appropriate level until this articular surface was adequately removed. at this point, the intramedullary canal and cancellous bone could be easily visualized. the opening hand reamers were then used and this was advanced to a size #10. under direct visualization, this was performed easily. at this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins. this was then removed. a trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured. it did not appear overstuffed with evidence of excellent range of motion and no impingement. at this point, the trial component was removed. wound was copiously irrigated and suctioned dry. cement was then placed with a cement gun into the canal and taken up to the level of the cut. the prosthesis was then inserted into place and held under direct visualization. all excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself. this _______ cement was adequately hard at this point. the final component of the head was impacted into place, secured on the morris taper and checked, and this was reduced.,the final component was then taken through range of motion and found to have excellent stability and was satisfied with its position. the wound was again copiously irrigated and suctioned dry. at this point, the capsule was then reattached to its insertion site in the anterior portion. once adequately sutured with #1-vicryl, attention was directed to the subscapular. the subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity. this was opened to allow some type of coverage points of the massive rotator cuff tear. this was secured to the tissue and interosseous sutures with size #2 fiber wire. after this was adequately secured, the wound was again copiously irrigated and suctioned dry. the deltoid fascial split was then repaired using interrupted #2-0 vicryl, subcutaneous tissue was then approximated using interrupted #24-0 vicryl, skin was approximated using a running #4-0 vicryl. steri-strips and adaptic, 4 x 4s, and abds were then applied. the patient was then placed in a sling and transferred back to the gurney, reversed by department of anesthesia.,disposition: , the patient tolerated well and transferred to postanesthesia care unit in satisfactory condition.

chief complaint: , bladder cancer.,history of present illness:, the patient is a 68-year-old caucasian male with a history of gross hematuria. the patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. ct scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. urology referral was initiated and the patient was sent to be evaluated by dr. x. he eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial ct scan. this workup involved serum cortisol analysis as well as potassium and aldosterone and acth level measurement. all of this workup was found to be grossly negative. secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by dr. x and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. at that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to abcd urology for management and diagnosis. the patient presents today for evaluation by dr. y.,past medical history: , includes condyloma, hypertension, diabetes mellitus, hyperlipidemia, undiagnosed copd, peripheral vascular disease, and claudication. the patient denies coronary artery disease.,past surgical history:, includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade tcc specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. the patient denies any bowel resection or gu injury at that time; however, he is unsure.,current medications:,1. metoprolol 100 mg b.i.d.,2. diltiazem 120 mg daily.,3. hydrocodone 10/500 mg p.r.n.,4. pravastatin 40 mg daily.,5. lisinopril 20 mg daily.,6. hydrochlorothiazide 25 mg daily.,family history: , negative for any gu cancer, stones or other complaints. the patient states he has one uncle who died of lung cancer. he denies any other family history.,social history: , the patient smokes approximately 2 packs per day times greater than 40 years. he does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. he denies any drug use. he is a retired liquor store owner.,physical examination:,general: he is a well-developed, well-nourished caucasian male, who appears slightly older than stated age. vital signs: temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. head and neck: normocephalic atraumatic. lungs: demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. heart: regular rate and rhythm. abdomen: soft and nontender. the liver and spleen are not palpably enlarged. there is a large midline defect covered by skin, of which the fascia has numerous holes poking through. these small hernias are of approximately 2 cm in diameter at the largest and are nontender. gu: the penis is circumcised and there are no lesions, plaques, masses or deformities. there is some tenderness to palpation near the meatus where 20-french foley catheter is in place. testes are bilaterally descended and there are no masses or tenderness. there is bilateral mild atrophy. epididymidis are grossly within normal limits bilaterally. spermatic cords are grossly within normal limits. there are no palpable inguinal hernias. rectal: the prostate is mildly enlarged with a small focal firm area in the midline near the apex. there is however no other focal nodules. the prostate is grossly approximately 35 to 40 g and is globally firm. rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. extremities: demonstrate no cyanosis, clubbing or edema. there is dark red urine in the foley bag collection.,laboratory exam:, review of laboratory from outside facility demonstrates creatinine of 2.38 with bun of 42. additionally, laboratory exam demonstrates a grossly normal serum cortisol, acth, potassium, aldosterone level during lesion workup. ct scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. there is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted.,impression:, bladder cancer.,plan: ,the patient will undergo a completion turbt on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. preoperative workup and laboratory as well as paper work were performed in clinic today with dr. y. the patient will be scheduled for anesthesia preop. the patient will have urine culture redrawn from his foley or penis at the time of preoperative evaluation with anesthesia. the patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. the patient understands these instructions and also agrees to quit smoking prior to his next visit. this patient was seen in evaluation with dr. y who agrees with the impression and plan.

title of operation: , transnasal transsphenoidal approach in resection of pituitary tumor.,indication for surgery: , the patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor. she was started on dostinex with increasing dosages. the most recent mri demonstrated an increased growth with hemorrhage. this was then discontinued. most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion. all the risks, benefits, and alternatives were explained in great detail via translator.,preop diagnosis: , pituitary tumor.,postop diagnosis: , pituitary tumor.,procedure detail: ,the patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine. the fluoroscope was then positioned. the approach will be dictated by dr. x. once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus. once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed. it appeared to be hemorrhagic and a necrotic pituitary, several sections were sent. once this was ensured and completed and hemostasis obtained, the wound was irrigated. there might have been a small csf leak with valsalva, so the recommendation was for a reconstruction, dr. x will dictate. the fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure. all sponge and needle counts were correct. the patient was extubated and transported to the recovery room in stable condition. blood loss was minimal.

procedures undertaken,1. left coronary system cineangiography.,2. right coronary system cineangiography.,3. cineangiography of svg to om.,4. cineangiography of lima to lad.,5. left ventriculogram.,6. aortogram.,7. percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,narrative:, after all risks and benefits were explained to the patient, informed consent was obtained. the patient was brought to the cardiac catheterization suite. the right groin was prepped in the usual sterile fashion. right common femoral artery was cannulated using a modified seldinger technique and a long 6-french ao sheath was introduced secondary to tortuous aorta. next, judkins left catheter was used to engage the left coronary system. cineangiography was recorded in multiple views. next, judkins right catheter was used to engage the right coronary system. cineangiography was recorded in multiple views. next, the judkins right catheter was used to engage the svg to om. cineangiography was recorded. next, the judkins right was advanced into the left subclavian and exchanged over a long exchange length j-wire for a 4-french left internal mammary artery which was used to engage the lima graft to lad and cineangiography was recorded in multiple views. next, an angled pigtail catheter was advanced into the left ventricular cavity. lv pressures were measured. lv gram was done and a pullback gradient across the aortic valve was done and recorded. next, an aortogram was done and recorded. at this point, i decided to proceed with percutaneous intervention of the left circumflex. therefore, ava 3.5 guide was used to engage the left coronary artery. angiomax bolus and drip was started. universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres. next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent. next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion. we next attempted a cutting balloon. again, we are unable to cross the lesion, therefore a buddy wire technique was used with a pt choice support wire. again, we were unable to cross the lesion with the stent. we then try to cross with a noncompliant balloon, which we were unsuccessful. we also try to cutting balloon again, we were unsuccessful. despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted. final images showed no evidence of dissection, perforation, or further complication. the right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results. the patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,diagnostic findings,1. the lv. lvedp was 4. lves is approximately 50%-55% with inferobasal hypokinesis. no significant mr. no gradient across the aortic valve.,2. aortogram. the ascending aorta shows no significant dilatation or evidence of dissection. the valve shows no significant aortic insufficiencies. the abdominal aorta and distal aorta shows significant tortuosities.,3. the left main. the left main coronary artery is a large caliber vessel, bifurcating the lad and left circumflex with some mild distal disease of about 10%-20%.,4. left circumflex. the left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch. the upper pole of the om shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis. the mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5. lad. the lad is a totally 100% occluded vessel. the lima to lad is patent with only a small-to-moderate caliber lad. there is a large diagonal branch coming off the proximal portion of the lad and that proximal lad showed some diffuse disease upwards of 60%-70%. the diagonal shows proximal 80% stenosis.,6. the right coronary artery: the right coronary artery is 100% occluded. there are retrograde collaterals from left to right to the distal pda and plv branches. the svg to om is 100% occluded at its take off. the svg to pda is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7. lima to lad is widely patent.,assessment and plan: , attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon. final images showed some improvement, however, continued residual stenosis. at this point, the patient will be transferred back to telemetry floor and monitored. we can attempt future intervention or continue aggressive medical management. the patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, i did not attempt intervention to that diagonal branch. possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.

preoperative diagnoses:,1. left breast mass.,2. hypertrophic scar of the left breast.,postoperative diagnoses:,1. left breast mass.,2. hypertrophic scar of the left breast.,procedure performed: ,excision of left breast mass and revision of scar.,anesthesia: ,local with sedation.,specimen: , scar with left breast mass.,disposition: ,the patient tolerated the procedure well and transferred to the recover room in stable condition.,brief history: ,the patient is an 18-year-old female who presented to dr. x's office. the patient is status post left breast biopsy, which showed a fibrocystic disease with now a palpable mass just superior to the previous biopsy site. the patient also has a hypertrophic scar. thus, the patient elected to undergo revision of the scar at the same time as an excision of the palpable mass.,intraoperative findings: , a hypertrophic scar was found and removed. the cicatrix was removed in its entirety and once opening the wound, the area of tissue where the palpable mass was, was excised as well and sent to the lab.,procedure: , after informed consent, risks, and benefits of the procedure were explained to the patient and the patient's family, the patient was brought to the operating suite, prepped and draped in the normal sterile fashion. elliptical incision was made over the previous cicatrix. the total length of the incision was 5.5 cm. removing the cicatrix in its entirety with a #15 blade bard-parker scalpel after anesthetizing with local solution with 0.25% marcaine. next, the area of tissue just inferior to the palpable mass, where the palpable was removed with electro bovie cautery. hemostasis was maintained. attention was next made to approximating the deep dermal layers. an interrupted #4-0 vicryl suture was used and then a running subcuticular monocryl suture was used to approximate the skin edges. steri-strips as well as bacitracin and sterile dressings were applied. the patient tolerated the procedure well and was transferred to recovery in stable condition.

preoperative diagnosis:, right middle lobe lung cancer.,postoperative diagnosis: , right middle lobe lung cancer.,procedures performed:,1. vats right middle lobectomy.,2. fiberoptic bronchoscopy thus before and after the procedure.,3. mediastinal lymph node sampling including levels 4r and 7.,4. tube thoracostomy x2 including a 19-french blake and a 32-french chest tube.,5. multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,anesthesia: ,general endotracheal anesthesia with double-lumen endotracheal tube.,disposition of specimens: , to pathology both for frozen and permanent analysis.,findings:, the right middle lobe tumor was adherent to the anterior chest wall. the adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis. the final frozen pathology on this entire area returned as negative for tumor. additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue. several other biopsies were taken and sent for permanent analysis of the chest wall. all of the biopsy sites were additionally marked with hemoclips. the right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,estimated blood loss: , less than 100 ml.,condition of the patient after surgery: , stable.,history of procedure:, this patient is well known to our service. he was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control. the patient was subsequently taken to the operating room on april 4, 2007, was given general anesthesia and was endotracheally intubated without incident. although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi. no abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery. the patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed. following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded. sterile duraprep preparation on the right chest was placed. a sterile drape around that was also placed. the table was flexed to open up the intercostal spaces. a second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube. marcaine was infused into all incision areas prior to making an incision. the incisions for the vats right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula. the camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used. third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein. all of these incisions were eventually created during the procedure. the initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port. these two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions. multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port. through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed. multiple biopsies were taken of the entire chest wall offers and specimens came back as negative. the right middle lobe was noted to be adherent to the anterior chest wall. this area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis. this also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells. based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy. following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed. the middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm endogia stapler. following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified. initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus. this was encircled and divided with a blue load stapler with a 45-mm endogia. following division of this, the pulmonary artery was easily identified. two branches of the pulmonary artery were noted to be going into the right middle lobe. these were individually divided with a vascular load after encircling with a right angle clamp. the vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe. a fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus. this was divided with a blue load stapler 45 mm endogia. following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe. following complete division of the fissure, the lobe was put into an endogia bag and taken out through the utility port. following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4r area as well as the 7 lymph node package. node station 8 or 9 nodes were easily identified, therefore none were taken. the patient was allowed to ventilate under water on the right lung with no obvious air leaking noted. a 19-french blake was placed into the posterior apical position and a 32-french chest tube was placed in the anteroapical position. following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again. following this, all the ports were closed with 2-0 vicryl suture used for the deeper tissue, and 3-0 vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 monocryl suture was used to close the skin in a running subcuticular fashion. the patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.

chief complaint: , burn, right arm.,history of present illness: , this is a workers' compensation injury. this patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. he has had it cooled, and presents with his friend to the emergency department for care.,past medical history: ,noncontributory.,medications: ,none.,allergies: ,none.,physical examination: , general: well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative. his only injury is to the right upper extremity. there are first and second degree burns on the right forearm, ranging from the elbow to the wrist. second degree areas with blistering are scattered through the medial aspect of the forearm. there is no circumferential burn, and i see no areas of deeper burn. the patient moves his hands well. pulses are good. circulation to the hand is fine.,final diagnosis:,1. first-degree and second-degree burns, right arm secondary to hot oil spill.,2. workers' compensation industrial injury.,treatment: , the wound is cooled and cleansed with soaking in antiseptic solution. the patient was ordered demerol 50 mg im for pain, but he refused and did not want pain medication. a burn dressing is applied with neosporin ointment. the patient is given tylenol no. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain. he is to return tomorrow for a dressing change. tetanus immunization is up to date. preprinted instructions are given. workers' compensation first report and work status report are completed.,disposition: , home.

reason for consult:, altered mental status.,hpi:, the patient is 77-year-old caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the physical medicine and rehab service for inpatient rehab after suffering a right cerebellar infarct last month. last night, he became confused and he eloped from the unit. when he was found, he became combative. this a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to haldol 1 mg intramuscularly. there was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital. given this presentation, psychiatry was consulted to evaluate and offer management recommendations.,the patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications. he reports feeling fine currently, denying any complaints. the patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment. she admits that he has some difficulty with memory for sometime and becomes irritable when she is not around. however, he has never become as combative as he has this particular episode.,he negates any symptoms of depression or anxiety. he also denies any hallucinations or delusions. he endorses problems with insomnia. at home, he takes temazepam. his wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,past psychiatric history:, he denies any prior psychiatric treatment or intervention. however, he was placed on zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia. during this hospital course, he was started on seroquel 20 mg p.o. q.h.s. in addition to aricept 5 mg daily. he denies any history of suicidal or homicidal ideations or attempts.,past medical history:,1. heart transplant in 1997.,2. history of abdominal aortic aneurysm repair.,3. diverticulitis.,4. cholecystectomy.,5. benign prostatic hypertrophy.,allergies:, morphine and demerol.,medications:,1. seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2. imodium 2 mg p.o. p.r.n., loose stool.,3. calcium carbonate with vitamin d 500 mg b.i.d.,4. prednisone 5 mg p.o. daily.,5. bactrim ds monday, wednesday, and friday.,6. flomax 0.4 mg p.o. daily.,7. robitussin 5 ml every 6 hours as needed for cough.,8. rapamune 2 mg p.o. daily.,9. zoloft 50 mg p.o. daily.,10. b vitamin complex daily.,11. colace 100 mg b.i.d.,12. lipitor 20 mg p.o. q.h.s.,13. plavix 75 mg p.o. daily.,14. aricept 5 mg p.o. daily.,15. pepcid 20 mg p.o. daily.,16. norvasc 5 mg p.o. daily.,17. aspirin 325 mg p.o. daily.,social history:, the patient is a retired paster and missionary to mexico. he is still actively involved in his church. he denies any history of alcohol or substance abuse.,mental status examination:, he is an average-sized white male, casually dressed, with wife and son at bedside. he is pleasant and cooperative with good eye contact. he presents with paucity of speech content; however, with regular rate and rhythm. he is tremulous which is worse with posturing also some increased motor tone noted. there is no evidence of psychomotor agitation or retardation. his mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content. his thoughts are circumstantial but logical. he defers most of his responses to his wife. there is no evidence of suicidal or homicidal ideations. no presence of paranoid or bizarre delusions. he denies any perceptual abnormalities and does not appear to be responding to internal stimuli. his attention is fair and his concentration impaired. he is oriented x3 and his insight is fair. on mini-mental status examination, he has scored 22 out of 30. he lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s. on category fluency, he was able to name 17 animals in one minute. he was unable to draw clock showing 2 minutes after 10. his judgment seems limited.,laboratory data:, calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, ptt 24.8, pt 14.1, inr 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000. urinalysis on january 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,diagnostic data:, mri of brain with and without contrast done on january 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,assessment:,axis i:,1. delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2. cognitive disorder, not otherwise specified, would rule out vascular dementia.,3. depressive disorder, not otherwise specified.

chief complaint:, back pain and right leg pain. the patient has a three-year history of small cell lung cancer with metastases.,history of present illness:, the patient is on my schedule today to explore treatment of the above complaints. she has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. she states she has had numerous chemotherapy and radiation treatments and told me that she has lost count. she says she has just finished a series of 10 radiation treatments for pain relief. she states she continues to have significant pain symptoms. most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee. she has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times. she complains of some diffuse, mid back pain. she describes the pain as sharp, dull, and aching in nature. she rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain. she states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking. she is on significant doses of narcotics. she has had multiple ct scans looking for metastasis.,past medical history:, significant for cancer as above. she also has a depression.,past surgical history:, significant for a chest port placement.,current medications:, consist of duragesic patch 250 mcg total, celebrex 200 mg once daily, iron 240 mg twice daily, paxil 20 mg daily, and percocet. she does not know of what strength up to eight daily. she also is on warfarin 1 mg daily, which she states is just to keep her chest port patent. she is on neurontin 300 mg three times daily.,habits:, she smokes one pack a day for last 30 years. she drinks beer approximately twice daily. she denies use of recreational drugs.,social history:, she is married. she lives with her spouse.,family history: , significant for two brothers and father who have cancer.,review of systems:, significant mainly for her pain complaints. for other review of systems the patient seems stable.,physical examination:,general: reveals a pleasant somewhat emaciated caucasian female.,vital signs: height is 5 feet 2 inches. weight is 130 pounds. she is afebrile.,heent: benign.,neck: shows functional range of movements with a negative spurling's.,chest: clear to auscultation.,heart: regular rate and rhythm.,abdomen: soft, regular bowel sounds.,musculoskeletal: examination shows functional range of joint movements. no focal muscle weakness. she is deconditioned.,neurologic: she is alert and oriented with appropriate mood and affect. the patient has normal tone and coordination. reflexes are 2+ in both knees and absent at both ankles. sensations are decreased distally in the left foot, otherwise intact to pinprick.,spine: examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement. the patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,functional examination: , gait has a normal stance and swing phase with no antalgic component to it.,investigation: , she has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally. she has had increased uptake in the sacroiliac joint regions bilaterally. ct of the chest showed no evidence of recurrent metastatic disease. ct of the abdomen showed no evidence of metastatic disease. mri of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs. ct of the pelvis showed a trabecular pattern with healed metastases. ct of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal ct scan. mr of the brain showed no acute intracranial abnormalities and no significant interval changes.,impression:,1. small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2. symptomatic facet and sacroiliac joint syndrome on the right.,3. chronic pain syndrome.,recommendations:, dr. xyz and i discussed with the patient her pathology. dr. xyz explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right. secondary to the patient's significant pain complaints today, dr. xyz will plan on injecting her right sacroiliac and facet joints under fluoroscopy today. i explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed. she understands that she is on warfarin therapy and that we generally do not perform injections while they are on this. we have asked for stat protime today. she is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications. she is on significant dose of narcotics already, however, she continues to have pain symptoms. dr. xyz advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra percocet if needed. i will plan on evaluating her in the clinic on tuesday. i have also asked that she stop her paxil, and we plan on starting her on cymbalta instead. she voiced understanding and is in agreement with this plan. i have also asked her to get an x-ray of the lumbar spine for further evaluation. physical exam, findings, history of present illness, and recommendations were performed with and in agreement with dr. g's findings. peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.

preoperative diagnosis: , left hip degenerative arthritis.,postoperative diagnosis: , left hip degenerative arthritis.,procedure performed: ,total hip arthroplasty on the left.,anesthesia: ,general.,blood loss: , 800 cc.,the patient was positioned with the left hip exposed on the beanbag.,implant specification: , a 54 mm trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,gross intraoperative findings: ,severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes. the patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis. this was revealed once we removed the trochanteric bursa.,history: ,this is a 56-year-old obese female with a history of bilateral degenerative hip arthritis. she underwent a right total hip arthroplasty by dr. x in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure. all risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure. the patient understood all these risks and was willing to continue further on with the procedure.,procedure: , the patient was wheeled back to the operating room #2 at abcd general hospital on 08/27/03. the general anesthetic was first performed by the department of anesthesia. the patient was then positioned with the left hip exposed on the beanbag in the lateral position. kidney rests were also used because of the patient's size. an axillary roll was also inserted for comfort in addition to a foley catheter, which was inserted by the or nurse. all her bony prominences were well padded. at this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure. at this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat. the tensor fascia lata was then identified. a self-retainer was then inserted to expose the operative field. bovie cautery was used for hemostasis. at this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter. at this time, a blunt dissection was taken proximally. the tensor fascia lata was occluded with a hip retractor. at this time, after hemostasis was obtained, bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius. at this time, a periosteal elevator was used to expose anterior hip capsule. a ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle. once this was performed, homan retractors were then inserted superiorly and inferiorly underneath the femoral neck. at this time, a capsulotomy was then performed using a bovie cautery and the capsulotomy was ________ and then edged over the acetabulum. at this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum. at this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum. at this time, a femoral stem guide was then used to measure proximal femoral neck cut. we made a cut approximately a fingerbreadth above the lesser trochanter. at this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,the femoral head was then removed. at this time, we removed the leg out of the bag and homan retractors were then used to expose the acetabulum. a long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum. with better exposure of the acetabulum, we started reaming the acetabulum. we started with a size #44 and progressively reamed to a size #50. at the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum. we then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum. a size 54 mm trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in. once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum. at this time, two screws were the placed within the superior table for better approaches securing the acetabular cup. at this time, a plastic liner was then inserted for protection. the leg was then placed back in the bag. a bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur. a rongeur was used to lateralize over the greater trochanter. a box osteotome was used to remove the cancellous portion of the femoral neck. a charnley awl was then used to cannulate through the proximal femoral canal. a power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem. at this time, we began broaching. we started with a size #10 and progressively worked up to a size #12 mm broach. once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar. a calcar reamer was then placed and the calcar was reamed smoothly. a standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed. once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation. at this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum. this was impacted and placed and checked to assure that it was well seated with no loosening. once this was performed, we then exposed the proximal femur one more time. we copiously irrigated within the canal and then suctioned it dry. at this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place. once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none. the 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the morse taper assured that this was well fixed by ________.,next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion. we were satisfied with components as well as the alignment of the components. copious irrigation was then used to irrigate the wound. #1 ethibond was then used to approximate the anterior hip capsule. #1 ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter. next, a #1 ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure. a tight closure was performed. since the patient did have a lot of subcutaneous fat, multiple #2-0 vicryl sutures were then used to approximate the bed space and then #2-0 vicryl for the subcutaneous skin. staples were then used for skin closure. the patient's hip was then cleansed. sterile dressings consisting of adaptic, 4 x 4, abds, and foam tape were then placed. a drain was placed prior to wound closure for postoperative drainage. after the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition. prognosis is good.

findings:,by dates the patient is 8 weeks, 2 days.,there is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. there is a fetal pole measuring 7mm consistent with 6 weeks 4 days. there was no fetal heart motion on doppler or on color doppler.,there is no fluid within the endometrial cavity.,there is a 2.8 x 1.2cm right adnexal cyst.,impression:,gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. by dates the patient is 8 weeks, 2 days.,a preliminary report was called by the ultrasound technologist to the referring physician.

admitting diagnoses:,1. fever.,2. otitis media.,3. possible sepsis.,history of present illness: ,the patient is a 10-month-old male who was seen in the office 1 day prior to admission. he has had a 2-day history of fever that has gone up to as high as 103.6 degrees f. he has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes. he has been taking tylenol and advil to help decrease the fevers, but the fever has continued to rise. he was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,past medical history: , significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,physical examination: , on exam, he was moderately ill appearing and lethargic. heent: atraumatic, normocephalic. pupils are equal, round, and reactive to light. tympanic membranes were red and yellow, and opaque bilaterally. nares were patent. oropharynx was slightly moist and pink. neck was soft and supple without masses. heart is regular rate and rhythm without murmurs. lungs showed increased workup of breathing, moderate tachypnea. no rales, rhonchi or wheezes were noted. abdomen: soft, nontender, nondistended. active bowel sounds. neurologic exam showed good muscle strength, normal tone. cranial nerves ii through xii are grossly intact.,laboratory findings: , he had electrolytes, bun and creatinine, and glucose all of which were within normal limits. white blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection. urinalysis was completely unremarkable. chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,hospital course: , the patient was admitted to the hospital and allowed a clear liquid diet. activity is as tolerates. cbc with differential, blood culture, electrolytes, bun, and creatinine, glucose, ua, and urine culture all were ordered. chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia. pulse oximetry checks were ordered every shift and as needed with o2 ordered per nasal cannula if o2 saturations were less that 94%. gave d5 and quarter of normal saline at 45 ml per hour, which was just slightly above maintenance rate to help with hydration. he was given ceftriaxone 500 mg iv once daily to treat otitis media and possible sepsis, and i will add tylenol and ibuprofen as needed for fevers. overnight, he did have his oxygen saturations drop and went into oxygen overnight. his lungs remained clear, but because of the need for o2, we instituted albuterol aerosols every 6 hours to help maintain good lung function. the nurses were instructed to attempt to wean o2 if possible and advance the diet. he was doing clear liquids well and so i saline locked to help to accommodate improve the mobility with the patient. he did well the following evening with no further oxygen requirement. he continued to spike fevers but last fever was around 13:45 on the previous day. at the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees f. with clear lungs. he was given additional dose of rocephin when it was felt that it would be appropriate for him to be discharged that morning.,condition of the patient at discharge: , he was at 100% oxygen saturations on room air with no further dips at night. he has become afebrile and was having no further increased work of breathing.,discharge diagnoses:,1. bilateral otitis media.,2. fever.,plan: ,recommended discharge. no restrictions in diet or activity. he was continued omnicef 125 mg/5 ml one teaspoon p.o. once daily and instructed to follow up with dr. x, his primary doctor, on the following tuesday. parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.

vital signs:, reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,constitutional: , normal appearance for chronological age, does not appear chronically ill.,heent: , the pupils are equal and reactive. funduscopic examination is normal. posterior pharynx is normal. tympanic membranes are clear.,neck: ,trachea is midline. thyroid is normal. the neck is supple. negative nodes.,respiratory:, lungs are clear to auscultation bilaterally. the patient has a normal respiratory rate, no signs of consolidation and no egophony. there are no retractions or secondary muscle use. good bilateral breath sounds are noted.,cardiovascular: , no jugular venous distention or carotid bruits. no increase in heart size to percussion. there is no murmur. normal s1 and s2 sounds are noted without gallop.,abdomen: , soft to palpation in all four quadrants. there is no organomegaly and no rebound tenderness. bowel sounds are normal. obturator and psoas signs are negative.,genitourinary: , no bladder tenderness, negative flank pain.,musculoskeletal:, extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,neurologic: , normal glasgow coma scale. cranial nerves ii through xii appear grossly intact. normal motor and cerebellar tests. reflexes are normal.,heme/lymph: ,no abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,psychiatric: , normal with no overt depression or suicidal ideations.

problems and issues:,1. headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and motrin for abortive treatment.,2. some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,history of present illness: , the patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. i obtained and documented a full history and physical examination. i reviewed the new patient questionnaire, which she completed prior to her arrival today. i also reviewed the results of tests, which she had brought with her.,briefly, she is a 60-year-old woman initially from ukraine, who had headaches since age 25. she recalls that in 1996 when her husband died her headaches became more frequent. they were pulsating. she was given papaverine, which was successful in reducing the severity of her symptoms. after six months of taking papaverine, she no longer had any headaches. in 2004, her headaches returned. she also noted that she had "zig-zag lines" in her vision. sometimes she would not see things in her peripheral visions. she had photophobia and dizziness, which was mostly lightheadedness. on one occasion she almost had a syncope. again she has started taking russian medications, which did help her. the dizziness and headaches have become more frequent and now occur on average once to twice per week. they last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,past medical history: ,her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,medications:, her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin d, centrum multivitamin tablets, actos, lorazepam as needed, vytorin, and celexa.,allergies: , she has no known drug allergies.,family history: ,there is family history of migraine and diabetes in her siblings.,social history: , she drinks alcohol occasionally.,review of systems: , her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. remainder of her full 14-point review of system was unremarkable.,physical examination:, on examination, the patient was pleasant. she was able to speak english fairly well. her blood pressure was 130/84. heart rate was 80. respiratory rate was 16. her weight was 188 pounds. her pain score was 0/10. her general exam was completely unremarkable. her neurological examination showed subtle weakness in her left arm due to discomfort and pain. she had reduced vibration sensation in her left ankle and to some degree in her right foot. there was no ataxia. she was able to walk normally. reflexes were 2+ throughout.,she had had a ct scan with constant, which per dr. x's was unremarkable. she reports that she had a brain mri two years ago which was also unremarkable.,impression and plan:, the patient is a delightful 60-year-old chemist from ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. she has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. her diagnosis is consistent with vestibular migraine. i do not see evidence of multiple sclerosis, ménière's disease, or benign paroxysmal positional vertigo.,i talked to her in detail about the importance of following a migraine diet. i gave her instructions including a list of foods times, which worsen migraine. i reviewed this information for more than half the clinic visit. i would like to start her on amitriptyline at a dose of 10 mg at time. she will take motrin at a dose of 800 mg as needed for her severe headaches.,she will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. i encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.

chief complaint:, jaw pain this morning.,brief history of present illness:, this is a very nice 53-year-old white male with no previous history of heart disease, was admitted to rule out mi and coronary artery disease. the patient has history of hypercholesterolemia, presently on lipitor 20 mg a day and hyperthyroidism, on synthroid 0.088 mg per day. also, history of chronic diverticulitis with recent bouts. the patient has been doing well, seen in my office at the end of december for complete physical examination. i had ordered a stress test for him, then delayed due to a family illness. however, denies any chest pain or chest tightness with exertion. the patient was doing well. he was watching television yesterday afternoon or p.m. and fell asleep holding his head in his left hand. he awoke and noticed pain in the jaw and neck area, on both sides, but no shortness of breath, diaphoresis, nausea, or chest pain. he is able to go to sleep, woke up this morning with same discomfort, decided to call our office, talked to our triage nurse, who instructed to come to the emergency room for possibility of just having a cardiac event. the patient's pain resolved. he was given nitroglycerin in the emergency room drawing his blood pressure 67/32. blood pressure quickly came back to normal with the patient's reverse trendelenburg.,family history: , strongly positive for heart disease in his father. he had a bypass at age 60. both parents are alive. both have dementia. his father has history of coronary artery disease and multiple vascular strokes. he is in his 80s. his mother is 80, also with dementia. the patient does not smoke or drink.,past medical history:, remarkable for tonsillectomies.,medications:, synthroid and lipitor.,allergies:, penicillin and biaxin.,review of systems:, noncontributory.,physical examination:,vital signs: the patient's blood pressure is 113/74, pulse rate is 72, respiratory rate is 18. he is afebrile.,general: he is well-developed, well-nourished white male, in no acute distress.,heent: pupils equal, round, and reactive to light and accommodation. extraocular movements were intact. throat was clear.,neck: supple. there is no organomegaly or thyromegaly. carotids are +2 without bruits.,chest: lungs are clear to auscultation and percussion.,cv: without any murmurs or gallops.,abdomen: soft. there is no hepatosplenomegaly. bowel sounds are active. no tenderness.,extremities: no cyanosis, clubbing, or edema. peripheral pulses 2+.,neurological: intact. motor exam is 5/5.,laboratory studies:, ekg is within normal limits, good sinus rhythm. his axis is somewhat leftward. cbc and bmp were normal and cardiac enzymes were negative x1.,impression:,1. jaw pain, sounds musculoskeletal. we will rule out angina equivalent.,2. hypercholesterolemia.,3. hypothyroidism.,plan: , lipitor and thyroid have been ordered. his chest pain unit protocol for the stress thallium that will be done in the morning. if test is negative, we will discharge home. if positive, we will consult cardiology. the patient requests dr. abc.

preoperative diagnosis: , left cervical radiculopathy.,postoperative diagnosis: ,left cervical radiculopathy.,procedures performed:,1. c5-c6 anterior cervical discectomy.,2. bone bank allograft.,3. anterior cervical plate.,tubes and drains left in place: , none.,complications: , none.,specimen sent to pathology: , none.,anesthesia: , general endotracheal.,indications: , this is a middle-aged man who presented to me with left arm pain. he had multiple levels of disease, but clinically, it was c6 radiculopathy. we tested him in the office and he had weakness referable to that nerve. the procedure was done at that level.,description of procedure: , the patient was taken to the operating room at which time an intravenous line was placed. general endotracheal anesthesia was obtained. he was positioned supine in the operative area and the right neck was prepared.,an incision was made and carried down to the ventral spine on the right in the usual manner. an x-ray confirmed our location.,we were impressed by the degenerative change and the osteophyte overgrowth.,as we had excepted, the back of the disk space was largely closed off by osteophytes. we patiently drilled through them to the posterior ligament. we went through that until we saw the dura.,we carefully went to the patient's symptomatic, left side. the c6 foramen was narrowed by uncovertebral joint overgrowth. the foramen was open widely.,an allograft was placed. an anterior steffee plate was placed. closure was commenced.,the wound was closed in layers with steri-strips on the skin. a dressing was applied.,it should be noted that the above operation was done also with microscopic magnification and illumination.

subjective:, he is a 29-year-old white male who is a patient of dr. xyz and he comes in today complaining that he was stung by a yellow jacket wasp yesterday and now has a lot of swelling in his right hand and right arm. he says that he has been stung by wasps before and had similar reactions. he just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. he has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,objective:,vitals: his temperature is 98.4. respiratory rate is 18. weight is 250 pounds.,extremities: examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow. he says that it is really not painful or anything like that. it is really not all that red and no signs of infection at this time.,assessment:, wasp sting to the right wrist area.,plan:,1. solu-medrol 125 mg im x 1.,2. over-the-counter benadryl, ice and elevation of that extremity.,3. follow up with dr. xyz if any further evaluation is needed.

preoperative diagnosis: ,1. right carpal tunnel syndrome.,2.

subjective:, the patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. apparently, his brother had similar symptoms. they had eaten some chicken and then ate some more of it the next day, and i could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. but any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. the patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. he has not had any emesis today. he has urinated this morning. his parents are both concerned because he had a fever of 103 last night. also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. he has been drinking pedialyte, gatorade, white grape juice, and 7up, otherwise he has not been eating anything.,medications: ,none.,allergies: ,he has no known drug allergies.,review of systems:, negative as far as sore throat, earache, or cough.,physical examination:,general: he is awake and alert, no acute distress.,vital signs: blood pressure: 106/75. temperature: 99. pulse: 112. weight is 54 pounds.,heent: his tms are normal bilaterally. posterior pharynx is unremarkable.,neck: without adenopathy or thyromegaly.,lungs: clear to auscultation.,heart: regular rate and rhythm without murmur.,abdomen: benign.,skin: turgor is intact. his capillary refill is less than 3 seconds.,laboratory: , white blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos. his platelet count on his cbc is 215.,assessment:, viral gastroenteritis.,plan:, the parents did point out to me a rash that he had on his buttock. there were some small almost pinpoint erythematous patches of papules that have a scab on them. i did not see any evidence of petechiae. therefore, i just reassured them that this is a viral gastroenteritis. i recommended that they stop giving him juice and just go with the gatorade and water. he is to stay away from milk products until his diarrhea and stomach upset have calmed down. we talked about brat diet and slowly advancing his diet as he tolerates. they have used some kaopectate, which did not really help with the diarrhea. otherwise follow up as needed.

discharge diagnoses:,1. gram-negative rod bacteremia, final identification and susceptibilities still pending.,2. history of congenital genitourinary abnormalities with multiple surgeries before the 5th grade.,3. history of urinary tract infections of pyelonephritis.,operations performed: , chest x-ray july 24, 2007, that was normal. transesophageal echocardiogram july 27, 2007, that was normal. no evidence of vegetations. ct scan of the abdomen and pelvis july 27, 2007, that revealed multiple small cysts in the liver, the largest measuring 9 mm. there were 2-3 additional tiny cysts in the right lobe. the remainder of the ct scan was normal.,history of present illness: , briefly, the patient is a 26-year-old white female with a history of fevers. for further details of the admission, please see the previously dictated history and physical. ,hospital course:, gram-negative rod bacteremia. the patient was admitted to the hospital with suspicion of endocarditis given the fact that she had fever, septicemia, and osler nodes on her fingers. the patient had a transthoracic echocardiogram as an outpatient, which was equivocal, but a transesophageal echocardiogram here in the hospital was normal with no evidence of vegetations. the microbiology laboratory stated that the gram-negative rod appeared to be anaerobic, thus raising the possibility of organisms like bacteroides. the patient does have a history of congenital genitourinary abnormalities which were surgically corrected before the fifth grade. we did a ct scan of the abdomen and pelvis, which only showed some benign appearing cysts in the liver. there was nothing remarkable as far as her kidneys, ureters, or bladder were concerned. i spoke with dr. xyz of infectious diseases, and dr. xyz asked me to talk to the patient about any contact with animals, given the fact that we have had a recent outbreak of tularemia here in utah. much to my surprise, the patient told me that she had multiple pet rats at home, which she was constantly in contact with. i ordered tularemia and leptospirosis serologies on the advice of dr. xyz, and as of the day after discharge, the results of the microbiology still are not back yet. the patient, however, appeared to be responding well to levofloxacin. i gave her a 2-week course of 750 mg a day of levofloxacin, and i have instructed her to follow up with dr. xyz in the meantime. hopefully by then we will have a final identification and susceptibility on the organism and the tularemia and leptospirosis serologies will return. a thought of ours was to add doxycycline, but again the patient clinically appeared to be responding to the levofloxacin. in addition, i told the patient that it would be my recommendation to get rid of the rats. i told her that if indeed the rats were carriers of infection and she received a zoonotic infection from exposure to the rats, that she could be in ongoing continuing danger and her children could also potentially be exposed to a potentially lethal infection. i told her very clearly that she should, indeed, get rid of the animals. the patient seemed reluctant to do so at first, but i believe with some coercion from her family, that she finally came to the realization that this was a recommendation worth following., ,disposition,discharge instructions: , activity is as tolerated. diet is as tolerated.,medications: , levaquin 750 mg daily x14 days.,followup is with dr. xyz of infectious diseases. i gave the patient the phone number to call on monday for an appointment. additional followup is also with dr. xyz, her primary care physician. please note that 40 minutes was spent in the discharge.

preoperative diagnosis:, bladder lesions with history of previous transitional cell bladder carcinoma.,postoperative diagnosis: , bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,operation performed: ,cystoscopy, bladder biopsies, and fulguration.,anesthesia: , general.,indication for operation: , this is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy. he was treated for a large transitional cell carcinoma of the bladder with turbt in 2002 and subsequently underwent chemotherapy because of pulmonary nodules. he has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months. recent cystoscopy raises suspicion of another recurrence.,operative findings: , the entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder. scarring was noted along the base of the bladder from the patient's previous cysto turbt. ureteral orifice on the right side was not able to be identified. the left side was unremarkable.,description of operation: , the patient was taken to the operating room. he was placed on the operating table. general anesthesia was administered after which the patient was placed in the dorsal lithotomy position. the genitalia and lower abdomen were prepared with betadine and draped subsequently. the urethra and bladder were inspected under video urology equipment (25 french panendoscope) with the findings as noted above. cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area. each of these biopsy sites were fulgurated with bugbee electrodes. inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear. the patient's bladder was then emptied. cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area. there were no apparent complications, and the patient appeared to tolerate the procedure well. estimated blood loss was less than 15 ml.

chief complaint: ,hip pain.,history of presenting illness: ,the patient is a very pleasant 41-year-old white female that is known to me previously from our work at the pain management clinic, as well as from my residency training program, san francisco. we have worked collaboratively for many years at the pain management clinic and with her departure there, she has asked to establish with me for clinic pain management at my office. she reports moderate to severe pain related to a complicated past medical history. in essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23. she was given nonsteroidals at that time, which did help with this discomfort. with time, however, this became inadequate and she was seen later in san francisco in her mid 30s by dr. v, an orthopedist who diagnosed retroverted hips at hospital. she was referred for rehabilitation and strengthening. most of this was focused on her si joints. at that time, although she had complained of foot discomfort, she was not treated for it. this was in 1993 after which she and her new husband moved to the boston area, where she lived from 1995-1996. she was seen at the pain center by dr. r with similar complaints of hip and knee pain. she was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back. medications at that time were salicylate and ultram.,when she returned to portland in 1996, she was then working for dr. b. she was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case. subsequently, nuclear bone scans revealed osteoarthritis. orthotics were provided. she was given paxil and tramadol and subsequently developed an unfortunate side effect of grand mal seizure. during this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle. she has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since. she currently does not have an established cardiologist having just changed insurance plans. she is establishing care with dr. s, of rheumatology for her ongoing care. up until today, her pain medications were being written by dr. y prior to establishing with dr. l.,pain management in town had been first provided by the office of dr. f. under his care, followup mris were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis. a number of medications were attempted there, including fentanyl patches with flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation. she then transferred her care to ab cd, fnp under the direction of dr. k. her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens. because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,past medical history: ,1. attention deficit disorder.,2. tmj arthropathy.,3. migraines.,4. osteoarthritis as described above.,past surgical history:,1. cystectomies.,2. sinuses.,3. left ganglia of the head and subdermally in various locations.,4. tmj and bruxism.,family history: ,the patient's father also suffered from bilateral hip osteoarthritis.,medications:,1. methadone 2.5 mg p.o. t.i.d.,2. norco 10/325 mg p.o. q.i.d.,3. tenormin 50 mg q.a.m.,4. skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5. wellbutrin sr 100 mg q.d.,6. naprosyn 500 mg one to two pills q.d. p.r.n.,allergies: , iv morphine causes hives. sulfa caused blisters and rash.,physical examination: , a well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,vital signs: blood pressure 110/72 with a pulse of 68.,heent: normocephalic. atraumatic. pupils are equal and reactive to light and accommodation. extraocular motions are intact. no scleral icterus. no nystagmus. tongue is midline. mucous membranes are moist without exudate.,neck: free range of motion without thyromegaly.,chest: clear to auscultation without wheeze or rhonchi.,heart: regular rate and rhythm without murmur, gallop, or rub.,abdomen: soft, nontender.,musculoskeletal: there is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the si joints bilaterally. passive hip motion also elicits bilateral hip pain referred to the ipsilateral side. toe-heel walking is performed without difficulty. straight leg raises are negative. romberg's are negative.,neurologic: grossly intact. intact reflexes in all extremities tested. romberg is negative and downgoing.,assessment:,1. osteoarthritis.,2. chronic sacroiliitis.,3. lumbar spondylosis.,4. migraine.,5. tmj arthropathy secondary to bruxism.,6. mood disorder secondary to chronic pain.,7. attention deficit disorder, currently untreated and self diagnosed.,recommendations:,1. agree with rheumatology referral and review. i would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. given the patient's previous sulfa allergies, we would recommend decreasing her naprosyn usage.

comparison:, none.,medications:, lopressor 5mg iv at 0920 hours.,heart rate: ,recorded heart rate 55 to 57bpm.,exam:,initial unenhanced axial ct imaging of the heart was obtained with ecg gating for the purpose of coronary artery calcium scoring (agatston method) and calcium volume determination.,18 gauge iv intracath was inserted into the right antecubital vein.,a 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,multi-detector ct imaging was performed with a 64 slice mdct scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of isovue was administered followed by a 90cc saline “bolus chaser”. image reconstruction was performed using retrospective cardiac gating. calcium scoring analysis (agatston method and volume determination) was performed.,findings:,calcium score: the patient's total agatston calcium score is: 115. the agatston score for the individual vessels are: lm: 49. rca: 1. lad: 2. cx: 2. other: 62. the agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,quality assessment:, examination is of good quality with good bolus timing and good demonstration of coronary arteries.,left main coronary artery:, the left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. the vessel is of moderate size. there is an apparent second ostium, in a more normal anatomic location, but quite small. this has an extramural (non-malignant) course. there is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. there is no high grade stenosis but a flow-limiting lesion can not be excluded. the vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,left anterior descending coronary artery:, the left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. there is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. lad continues as a moderate-size vessel to the posterior apex of the left ventricle.,ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. the dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. the vessel continues as a small vessel on the left lateral ventricular wall.,left circumflex coronary artery:, the left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small om1 branch and a large om2 branch supplying much of the posterolateral wall of the left ventricular. the av-groove branch tapers at the base of the heart. there is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,right coronary artery:, the right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. there is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,coronary circulation is right dominant.,functional analysis:, end diastolic volume: 106ml end systolic volume: 44ml ejection fraction: 58 percent,anatomic analysis:,normal heart size with no demonstrated ventricular wall abnormalities. there are no demonstrated myocardial,bridges. normal left atrial appendage with no evidence of thrombosis.,cardiac valves are normal.,the aortic diameter measures 33mm just distal to the sino-tubular junction. the visualized thoracic aorta appears normal in size.,normal pericardium without pericardial thickening or effusion.,there is no demonstrated mediastinal or hilar adenopathy. the visualized lung parenchyma is unremarkable.,there are two left and two right pulmonary veins.,impression:,ventricular function: normal.,single vessel coronary artery analysis:,lm: there is a posterior origin from the valve cusp. there is mixed calcific/atheromatous plaque and positive remodeling plaque within the lm, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. in addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,lad: dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. there is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,cx: minimal calcific plaque with no flow-limiting lesion.,rca: minimal calcific plaque with no flow-limiting lesion.,coronary artery dominance: right.

preoperative diagnosis:, bilateral hydroceles.,postoperative diagnosis:, bilateral hydroceles.,procedure: , bilateral scrotal hydrocelectomies, large for both, and 0.5% marcaine wound instillation, 30 ml given.,estimated blood loss: , less than 10 ml.,fluids received: , 800 ml.,tubes and drains: , a 0.25-inch penrose drains x4.,indications for operation: ,the patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time. finally, he has decided to have them get repaired. plan is for surgical repair.,description of operation: ,the patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped. iv antibiotics were given. ancef 1 g given. a scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery. electrocautery was used for hemostasis. once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid. there was moderate amount of scarring on the testis itself from the tunica vaginalis. it was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a lord maneuver. once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation. a similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with lord maneuver similarly. this testis also was normal but had moderate amount of scarring on the tunic vaginalis from this. a similar drain was placed. the testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 ml of 0.5% marcaine without epinephrine. iv toradol was given at the end of the procedure. the skin was then sutured with a running interlocking suture of 3-0 vicryl and the drains were sutured to place with 3-0 vicryl. bacitracin dressing, abd dressing, and jock strap were placed. the patient was in stable condition upon transfer to the recovery room.

general: , alert, well developed, in no acute distress.,mental status: , judgment and insight appropriate for age. oriented to time, place and person. no recent loss of memory. affect appropriate for age.,eyes: ,pupils are equal and reactive to light. no hemorrhages or exudates. extraocular muscles intact.,ear, nose and throat: , oropharynx clean, mucous membranes moist. ears and nose without masses, lesions or deformities. tympanic membranes clear bilaterally. trachea midline. no lymph node swelling or tenderness.,respiratory: ,clear to auscultation and percussion. no wheezing, rales or rhonchi.,cardiovascular: , heart sounds normal. no thrills. regular rate and rhythm, no murmurs, rubs or gallops.,gastrointestinal: , abdomen soft, nondistended. no pulsatile mass, no flank tenderness or suprapubic tenderness. no hepatosplenomegaly.,neurologic: , cranial nerves ii-xii grossly intact. no focal neurological deficits. deep tendon reflexes +2 bilaterally. babinski negative. moves all extremities spontaneously. sensation intact bilaterally.,skin: , no rashes or lesions. no petechia. no purpura. good turgor. no edema.,musculoskeletal: , no cyanosis or clubbing. no gross deformities. capable of free range of motion without pain or crepitation. no laxity, instability or dislocation.,bone: , no misalignment, asymmetry, defect, tenderness or effusion. capable of from of joint above and below bone.,muscle: ,no crepitation, defect, tenderness, masses or swellings. no loss of muscle tone or strength.,lymphatic:, palpation of neck reveals no swelling or tenderness of neck nodes. palpation of groin reveals no swelling or tenderness of groin nodes.

preoperative diagnosis:, senile cataract ox,postoperative diagnosis: ,senile cataract ox,procedure: ,phacoemulsification with posterior chamber intraocular lens ox, model sn60at (for acrysof natural lens), xxx diopters.,indications: ,this is a xx-year-old (wo)man with decreased vision ox.,procedure:, the risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. informed consent was obtained. on the day of surgery, (s)he received several sets of drops in the xxx eye including 2.5% phenylephrine, 1% mydriacyl, 1% cyclogyl, ocuflox and acular. (s)he was taken to the operating room and sedated via iv sedation. 2% lidocaine jelly was placed in the xxx eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). the xxx eye was prepped using a 10% betadine solution. (s)he was covered in sterile drapes leaving only the xxx eye exposed. a lieberman lid speculum was placed to provide exposure. the thornton fixation ring and a superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. then 1% lidocaine was injected through the paracentesis. after the nonpreserved lidocaine was injected, viscoat was injected through the paracentesis to fill the anterior chamber. the thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. the cystitome and utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. bss on a hydrodissection cannula was used to perform gentle hydrodissection. phacoemulsification was then performed to remove the nucleus. i & a was performed to remove the remaining cortical material. provisc was injected to fill the capsular bag and anterior chamber. a xxx diopter sn60at (for acrysof natural lens) intraocular lens was injected into the capsular bag. the kuglen hook was used to rotate it into proper position in the capsular bag. i & a was performed to remove the remaining viscoelastic material from the eye. bss on the 30-gauge cannula was used to hydrate the wound. the wounds were checked and found to be watertight. the lid speculum and drapes were carefully removed. several drops of ocuflox were placed in the xxx eye. the eye was covered with an eye shield. the patient was taken to the recovery area in a good condition. there were no complications.

preoperative diagnosis: ,closed displaced angulated fracture of the right distal radius.,postoperative diagnosis: , closed displaced angulated fracture of the right distal radius.,procedure: , open reduction and internal fixation (orif) of the right wrist using an acumed locking plate.,anesthesia: , general laryngeal mask airway.,estimated blood loss: , minimal.,tourniquet time: , 40 minutes.,complications: , none.,the patient was taken to the postanesthesia care unit in stable condition. the patient tolerated the procedure well.,indications: ,the patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist. he was placed into a well-molded splint after reduction was performed in the emergency department. further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted. all risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for orif of the right wrist.,procedure: , the patient was taken to the operating suite, placed in supine position on the operative table. the department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well. the right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmhg pressure. the right upper extremity was prepped and draped in a sterile fashion. a 5-cm incision was made over the flexor carpi radialis of the right wrist. the skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus. sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue. next, a reduction was performed placing the distal fragment into appropriate alignment. this was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position. an acumed accu-lock plate was placed along the volar aspect of the distal radius. this was checked under ap and lateral views with c-arm, noted to be in appropriate alignment. a 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position. two distal locking screws were placed along the plate itself. the screws were checked under ap and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular. four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate. all locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture. ap and lateral views were taken of these screw placements again. none of these screws were into the joint and all had appropriate length into the dorsal cortex. two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase. ap and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws. bicortical purchase was appreciated and no screws were placed into the joint. the wound itself was copiously irrigated with saline and kantrex after which the subcutaneous tissue was approximated with 2-0 vicryl, and the skin was closed with running 4-0 nylon stitch; 10 ml of 0.5% marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint. the patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition. the patient tolerated the procedure well.

family history: , his parents are deceased. he has two brothers ages 68 and 77 years old, who are healthy. he has siblings, a brother and a sister who were twins who died at birth. he has two sons 54 and 57 years old who are healthy. he describes history of diabetes and heart attack in his family.,social history: ,he is married and has support at home. he denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.,allergies:, garamycin.,medications: , insulin 20 to 25 units twice a day. lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it. glipizide 5 mg with each meal, advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., centrum az q.d.,past medical history: ,the patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. he also has a history of prostate cancer, which was treated by radiation. he says his psa is at 0.01.,past surgical history:, in 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer.,review of systems: , musculoskeletal: he is right-handed. respiratory: for shortness of breath. urinary: for frequent urination. gi: he denies any bowel or bladder dysfunction. genital: he denies any loss of sensation or erectile problems. heent: negative and noncontributory. hem-onc: negative and noncontributory. cardiac: negative and noncontributory. vascular: negative and noncontributory. psychiatric: negative and noncontributory.,physical examination: , he is 5 feet 10 inches tall. current weight is 204 pounds, weight one year ago was 212. bp is 130/66. pulse is 78. on physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. heent exam, head is atraumatic and normocephalic. eyes, sclerae are anicteric. teeth, poor dentition. cranial nerves ii, iii, iv, and vi, vision intact, visual fields full to confrontation, eoms full bilaterally, and 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. cranial nerves ix, x, and xii, tongue protrudes midline and palate elevates symmetrically. cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2. chest and lungs are clear bilaterally. skin is warm and dry, normal turgor and texture. no rashes or lesions are noted. peripheral vascular, no cyanosis, clubbing, or edema is noted. general musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. station and gait are appropriate. he ambulates well without any difficulties or assistance. no antalgic or spastic gait is noted. examination of the low back reveals no paralumbar spasms. he is nontender to palpation over his spinous process, si joints, or paralumbar musculature. deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles. no ankle clonus is elicited. babinski, toes are downgoing. sensation is intact.,he does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left. strength is 5/5 and equal bilateral lower extremities. he is able to ambulate on his toes and his heels without any weakness noted. he has negative straight leg raising bilaterally.,findings:, the patient brings in lumbar spine mri for 11/15/2007, which demonstrates degenerative disc disease throughout. at l4-l5 and l5-s1 he has severe disc space narrowing. at l3-l4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing. at l4-l5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis. at l5-s1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left.,assessment: , low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation.,plan: , we discussed treatment options with this patient including:,1. do nothing.,2. conservative therapies.,3. surgery.,the patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed. we went ahead and obtained an ekg in the office today due to the fact that i heard a murmur on exam. i did phone the patient's primary care doctor, dr. o. unfortunately dr. o is out of the country, and i did speak with dr. k, who is covering for dr. o. i informed dr. k that the patient had a new-onset murmur and that i did have some concerns for the patient does not recollect having this diagnosis before, so i obtained an ekg. a copy was provided to the patient and the patient was referred back to his primary care physician for workup. he was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.,all questions and concerns were addressed. if he should have any further questions, concerns, or complications, he will contact our office immediately. otherwise, we will see him p.r.n. warning signs and symptoms were gone over with him. case was reviewed and discussed with dr. l.

history: , the patient is to come to the hospital for bilateral l5 kyphoplasty. the patient is an 86-year-old female with an l5 compression fracture.,the patient has a history of back and buttock pain for some time. she was found to have an l5 compression fracture. she was treated conservatively over several months, but did not improve. unfortunately, she has continued to have significant ongoing back pain and recent ct scan has shown a sclerosis with some healing of her l5 compression fracture, but without complete healing. the patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,she denies bowel or bladder incontinence. she does complain of back pain. she has been wearing a back brace and corset. she does not have weakness.,past medical history:, the patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,past surgical history:, she has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. she also has a diagnosis of polymyalgia rheumatica.,current medications: , she is on multiple medications currently.,allergies: , she is allergic to codeine, penicillin, and cephalosporins.,family history: , the patient's parents are deceased.,personal and social history: , the patient lives locally. she is a widow. she does not smoke cigarettes or use illicit drugs.,physical examination: , general: the patient is an elderly frail white female in no distress. lungs: clear. heart: sounds are regular. abdomen: she has a protuberant abdomen. she has tenderness to palpation in the lumbosacral area. sciatic notch tenderness is not present. straight leg raise testing evokes back pain. neurological: she is awake, alert, and oriented. speech is intact. comprehension is normal. strength is intact in the upper extremities. she has giveaway strength in the lower extremities. reflexes are diminished at the knees and ankles. gait is otherwise normal.,data reviewed: , plain studies of the lumbar spine show an l5 compression fracture. a ct scan has shown some healing of this fracture. she has degenerative change at the l4-l5 level with a very slight spondylolisthesis at this level.,assessment and plan: , the patient is a woman with a history of longstanding back, buttock, and leg pain. she has a documented l5 compression fracture, which has not healed despite appropriate conservative treatments. at this point, i believe the patient is a good candidate for l5 kyphoplasty. i have discussed the procedure with her and i have reviewed with her and her family risks, benefits, and alternatives to surgery. risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed. the patient understands the issues involved. she requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.

diagnosis:, nuclear sclerotic and cortical cataract, right eye.,operation:, phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,procedure:, the patient was taken to the operating room and placed on the table in the supine position. cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff. local anesthesia was obtained using 2% lidocaine, 0/75% marcaine, 0.5 cc wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage. the patient was then prepped and draped in the usual sterile fashion for eye surgery. with the zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle. with westcott scissors, a fornix-based conjunctival flap was made. the surgical limbus was identified and hemostasis obtained with wet-field cautery. with a 57-beaver blade, a corneoscleral groove was made and shelved into clear cornea. a stab incision was made at 2 o'clock with a 15-degree blade. with a 3.0 mm keratome, the shelved groove was attended into the anterior chamber. viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique. hydrodissection was performed with balanced salt solution. phacoemulsification was performed in a two-headed nuclear fracture technique. the remaining cortical material was removed with irrigation and aspiration handpiece. the posterior capsule remained intact and vacuumed with minimal suction. the posterior chamber intraocular lens was obtained. it was inspected, irrigated, inserted into the posterior chamber without difficulty. inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound. there was no aqueous leak even with digital pressure. the conjunctiva was pulled back into position with wet-field cautery. a subconjunctival injection with 20 mg gatamycine and 0.5 cc celestone was given. tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture. the patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.

allowed conditions:, sprain of left knee and leg.,contested condition:, left knee tear medial meniscus, left knee acl tear.,employer:, yyyy,requesting party:, xxxx,mr. xxxxxx is a xx-year-old male who was evaluated for an independent medical examination on september 20, 2007, because of an injury sustained to the left leg. the injured worker does state that he was working as a processor for the abcd company on july 18, 2007, when he injured his left knee. he does state he was working in a catwalk when he stepped up. he noticed his sight glass was not open on the tank. he then stepped straight down and his knee went sideways. his knee popped and he sat down secondary to discomfort. at that time he could not do any type of activity secondary to the pain. the nurse called the ambulance subsequent to this injury and he was taken to bethesda north. x-rays were obtained which demonstrated no evidence of fracture. thereafter, he was referred to x who he saw on july 19, 2007. it was felt that a mri scan about the knee needed to be obtained and it was obtained on july 24. it was noted that there was evidence of an anterior cruciate ligament tear and a slight medial meniscal tear. on his second visit, it was felt that arthroscopic surgery intervention was indicated as related to the left knee.,on september 7, 2007, he underwent surgical intervention at abc for the anterior cruciate reconstruction as well as the partial medial meniscectomy.,at the present time, he is progressing along with physical therapy. he is utilizing one crutch.,he does admit to significant bruising and swelling about the left lower extremity. if he does indeed move too fast, the discomfort is increased. his pain about the left knee is approximately 6 to 7 on a scale of 1 to 10.,he has had injuries to the right knee in which he wrecked his bicycle and did have some type of fracture bone spur when he was 13 years of age.,he underwent arthroscopic surgery as related to the right knee at that time and really did quite well.,his next appointment with dr. x is on october 4, 2007.,the injured worker denies any previous history of similar problems as related to the left knee.,medications: , glucophage, lipitor, actos, benicar, glimepiride, and januvia.,surgical history:, arthroscopic surgery of the left knee and arthroscopic surgery of the right knee.,social history:, the patient denies alcohol consumption. he does smoke approximately one and a half packs of cigarettes per day. his education is that of 12th grade.,physical examination: , this is a healthy appearing 34-year-old male who is 5 feet 9 inches and weighs 285 pounds. he does not appear to be in distress at this time. examination is limited to the left knee. one could appreciate a healed scar as related to the inferior pole inferior to the patella. there are healed arthroscopic scars as well. the range of motion of left knee reveals 50 to 70 degrees of flexion. there is evidence of medial and lateral joint line discomfort. anterior lachman's test was negative. no evidence of atrophy is noted. there is weakness with aggressive function about the quadriceps and hamstring musculature.,the patient is ambulating with one crutch at this time.,there is mild degree of swelling as related to the left knee. deep tendon reflexes are +2/+2 bilaterally symmetrical. sensory examination was normal as related to the foot, but abnormal as related to the left knee.,i did review pictures that were taken at the time of the surgery, which demonstrates the meniscectomy and the anterior cruciate ligament reconstruction.,medical records review:,1. july 18, 2007, x-rays of the left knee demonstrated evidence of a small suprapatellar joint effusion. it should be noted that the exam demonstrated evidence of medial and lateral joint line discomfort. there was specific mention of intraarticular effusion.,2. on july 27, 2007, mri scan of the left knee was obtained, which demonstrated evidence of the complete tear of the mid to distal acl. findings suggestive of a chronic injury. grade i sprain of the mcl was noted. contusion __________ plateau medial femoral condyle and lateral femoral condyle was noted. there was evidence of a small peripheral longitudinal tear of the posterior horn of medial meniscus. chondromalacia of the lateral femoral condyle and patella was noted. it should be noted that the changes of degeneration of the cartilages of the injured worker's knee and the chronic anterior cruciate ligament changes were noted related to the july 18, 2007, injury.,3. july 18, 2007, first report of injury, occupational disease, and/or death.,4. evaluations of abcd hospital. it should be noted that the mechanism of injury was such that he was walking down the stairs when his left knee locked up.,5. july 18, 2007, x-rays of the left knee were obtained, which demonstrated the evidence of no acute fracture or significant osteoarthritis. there is evidence there maybe a small suprapatellar joint effusion.,6. notes from the office of dr. x. it should be noted on physical examination his range of motion is 8 to 20 degrees.,7. physical therapy prescription for __________ orthopedics and sports medicine corporation.,8. august 10, 2007, requests for arthroscopic anterior cruciate ligament reconstruction with patellar tendon.,9. physician narrative of august 24, 2007. it is noted that the injured worker did indeed have evidence of hypertension, hyperlipidemia, and diabetes. his bmi was 42. this was felt __________ pre-injury mri scan.,following your review of the medical information and your physical examination, please answer the following questions as these pertain to the allowed conditions. please express your opinion based upon a reasonable degree of medical probability.,question: ,mr. xxxxxx has filed an application for the additional allowance of left knee tear of the medial meniscus and left knee acl tear.,based on the current objective findings, mechanism of injury, or and medical records or diagnosis studies, does the medical evidence support the existence of any of the requested conditions.,answer: ,the mri sustains and verifies that these conditions do indeed exist subsequent to the injury of july 18, 2007.,question: ,if you find any of these conditions exist, are they a direct and proximate result of the july 18, 2007, injury.,answer: ,there is mention of degeneration as related to the knee prior to this episode. this is not surprising considering the individual's weight. there is no question degeneration as related to anterior cruciate ligament and the meniscus has been occurring for a lengthy period of time. there has been an aggravation of this condition. without having a mri to review prior to this injury, i believe, it would be safe to assume that there has been aggravation of a pre-existing condition as related to the left knee and __________ meniscal and anterior cruciate ligament pathology. thus there is definitely evidence of an aggravation of a pre-existing condition but not necessarily a direct and proximate result of the july 18, 2007, injury.,question:

cc: ,headache.,hx: ,this 37y/o lhm was seen one month prior to this presentation for ha, nausea and vomiting. gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. these symptoms had been recurrent since onset.,at presentation he complained of mild blurred vision (ou), difficulty concentrating and ha which worsened upon sitting up. the headaches were especially noticeable in the early morning. he described them as non-throbbing headaches. they begin in the bifrontal region and radiate posteriorly. they occurred up to 6 times/day. the ha improved with lying down or dropping the head down between the knees towards the floor. the headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. he denied any scotomata or positive visual phenomena. he denies any weakness, numbness, tingling, dysarthria or diplopia. his weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. his appetite has been especially poor in the past month.,meds:,sulfasalazine qid. tylenol 650mg q4hours.,pmh:, 1)ulcerative colitis dx 1989. 2)htn 3) occasional has since the early 1980s which are different in character and much less severe than his current has. they were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,fhx:, mgf with h/o stroke. mother and father were healthy. no h/o of migraine in family.,shx:, single. works as a newpaper printing press worker. denies tobacco, etoh or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,exam: ,bp159/92 hr 48 (sitting): bp126/70 hr48 (supine). rr14 36.2c,ms: a&o to person, place and time. speech clear. appears uncomfortable but acts appropriately and cooperatively. no difficulty with short and long term memory.,cn: grad 2-3 papilledema os; grade 1 papilledema (@2 o'clock) od. pupils 4/4 decreasing to 2/2 on exposure to light. bilateral horizontal sustained nystagmus on right and leftward gaze. bilateral vertical sustained nystagmus on up and downward gaze. face symmetric with full movement and pp sensation. tongue midline with full rom. gag and scm were intact bilaterally.,motor: full strength throughout with normal muscle bulk and tone.,sensory: unremarkable.,coord: mild dysynergia on fnf movements in bue. hns and ram were unremarkable.,station: unsteady with and without eyes open on romberg test. no drift in any particular direction.,gait: wide based, ataxic and to some degree magnetic and apraxic.,gen exam: unremarkable.,course:, urinalysis revealed 1-2rbc, 2-3wbc and bacteria were noted. repeat urinalysis was negative the next day. pt, ptt, cxr and gs were normal. cbc revealed 10.4wbc with 7.1granulocytes. hct, 10/18/95, revealed hydrocephalus. mri, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. there was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of magendie. these changes were felt suggestive of bacterial or granulomatous meningitis. the patient underwent ventriculostomy on 10/19/94. csf taken on 10/19/94 via v-p shunt insertion revealed: 22 wbc (21 lymphocytes, 1 monocyte), 380 rbc, glucose 58, protein 29, gs negative, cultures (bacterial, fungal, afb) negative, cryptococcal antigen and india ink were negative. numerous csf samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional csf protein of up to 99mg/dl. serum and csf toxoplasma titers and ace levels were negative on multiple occasions. vdrl and hiv testing was unremarkable. 10/27/94 and 10/31/94 csf cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. the patient was treated with amphotericin and showed some improvement. however, scarring had probably occurred by then and the v-p shunt was left in place.

preoperative diagnoses: , cholelithiasis, cholecystitis, and recurrent biliary colic.,postoperative diagnoses: , severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,procedures performed: , laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and t-tube drainage of the common bile duct.,anesthesia: , general.,indications: , this is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain. the patient was found to have cholelithiasis on last admission. he was being worked up for this including cardiac clearance. however, in the interim, he returned again with another episode of same pain. the patient had a hida scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction. because of these, laparoscopic cholecystectomy was advised with cholangiogram. possibility of open laparotomy and open procedure was also explained to the patient. the procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,description of procedure: , the patient was put in supine position on the operating table under satisfactory general anesthesia. the entire abdomen was prepped and draped. a small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia. the patient has a rather long torso. fascia was opened vertically and stay sutures were placed in the fascia. peritoneal cavity was carefully entered. hasson cannula was inserted into the peritoneal cavity and it was insufflated with co2. laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area. the patient was placed in reverse trendelenburg and rotated to the left. an 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region. slowly, the dissection was carried out in the right subhepatic area. initially, i was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver. then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation. the visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick. after evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy. the trocars were removed.,a right subcostal incision was made and peritoneal cavity was entered. a bookwalter retractor was put in place. the dissection was then carried out on the undersurface of the liver. eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it. dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size. the duodenum was kocherized. the gallbladder was partly intrahepatic. because of this, i decided not to dig it out of the liver bed causing further bleeding and problem. the inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,it was difficult to tell where the cystic duct was. eventually after probing near the neck of the gallbladder, i did find the cystic duct, which was relatively very short. intraoperative cystic duct cholangiogram was done using c-arm fluoroscopy. this showed a rounded density at the lower end of the bile duct consistent with the stone. at this time, a decision was made to proceed with common duct exploration. the common duct was opened between stay sutures of 4-0 vicryl and immediately essentially clear bile came out. after some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct. so, it was about a 1-cm size stone, which was removed. following this, a 10-french red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously. no further stones were obtained. the catheter went easily into the duodenum through the ampulla of vater. at this point, a choledochoscope was inserted and proximally, i did not see any evidence of any common duct stones or proximally into the biliary tree. however, a stone was found distally still floating around. this was removed with stone forceps. the bile ducts were irrigated again. no further stones were removed. a 16-french t-tube was then placed into the bile duct and the bile duct was repaired around the t-tube using 4-0 vicryl interrupted sutures obtaining watertight closure. a completion t-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, i was unable to see anything or palpate anything in this area. because of this, the t-tube was removed, and i passed the choledochoscope proximally again, and i was unable to see any evidence of any lesion or any stone in this area. i felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct. the bile duct lumen was widely open. t-tube was again replaced into the bile duct and closed again and a completion t-tube cholangiogram appeared to be more satisfactory at this time. the cystic duct opening through which i had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,the remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining. subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution. hemostasis was good. a 10-mm jackson-pratt drain was left in the foramen of winslow and brought out through the lateral 5-mm port site. the t-tube was brought out through the middle 5-mm port site, which was just above the incision. abdominal incision was then closed in layers using 0 vicryl running suture for the peritoneal layer and #1 novafil running suture for the fascia. subcutaneous tissue was closed with 3-0 vicryl running sutures in two layers. subfascial and subcutaneous tissues were injected with a total of 20 ml of 0.25% marcaine with epinephrine for postoperative pain control. the umbilical incision was closed with 0 vicryl figure-of-eight sutures for the fascia, 2-0 vicryl for the subcutaneous tissues, and staples for the skin. sterile dressing was applied, and the patient transferred to recovery room in stable condition.

title of operation:, total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,indication for surgery: , a 58-year-old gentleman who has had a history of a t3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07. subsequently, biopsy confirmed tumor persistence in the right glottic region. risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail. also concerned for a ct scan finding of possible cartilaginous invasion at the cricoid level. the patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives. he was accompanied by his wife and daughter. risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,preop diagnosis: , squamous cell carcinoma of the larynx.,postop diagnosis: , squamous cell carcinoma of the larynx.,procedure detail: , after identifying the patient, the patient was placed supine on the operating room table. after the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with tegaderm. a #6 endotracheal tube was placed initially. direct laryngoscopy was performed with a lindholm laryngoscope. a 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis. subsequently, a decision was then made to go ahead and perform the surgical intervention. a hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected. a shoulder roll was applied after the patient was prepped and draped in a sterile fashion. subsequently, a hemi-apron incision was performed. subplatysmal flaps were raised at the hyoid bone into the clavicle. attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed. submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle. digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle. the fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve xi was identified. level 2a contents were then dissected off the floor of the neck including levels 3 and 4. preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4. the specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve. levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed. subsequently, the strap muscles were separated in the midline. the trachea was identified in the midline. the thyroid isthmus was plicated using the harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage. once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively. the cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular. attention was then turned to performing a cricothyrotomy. upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision. a #7 anode tube was then placed in this area and secured. attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis. subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine. it was evident that this tumor had extended more than 1 cm into the subglottic region. careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded. frozen section biopsy then confirmed this finding as read by dr. x of surgical pathology.,in light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy. subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin. a w-plasty was also performed to allow for enlargement of the stoma. attention was then turned to identifying the common parting wall of the trachea and the esophagus. attention was then turned to resecting the hyoid bone. the remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism. the wound was copiously irrigated. subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect. once this was performed, a running 3-0 canal stitch was used to close the pharynx. subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied. two #10 jp drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon. the wound was then closed using interrupted 3-0 vicryl for the platysma and staples for the skin. the patient tolerated the procedure well and was brought to the weinberg intensive care unit with the endotracheal tube still in place to be decannulated later.

preoperative diagnosis: , shunt malfunction. the patient with a ventriculoatrial shunt.,postoperative diagnosis:, shunt malfunction. the patient with a ventriculoatrial shunt.,anesthesia: , general endotracheal tube anesthesia.,indications for operation: , headaches, fluid accumulating along shunt tract.,findings: , partial proximal shunt obstruction.,title of operation:, endoscopic proximal shunt revision.,specimens: , none.,complications:, none.,devices: , portnoy ventricular catheter.,operative procedure:, after satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner. the old right frontal scalp incision was reopened in a curvilinear manner, and the bactiseal ventricular catheter was identified as it went into the right frontal horn. the distal end of the va shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped. endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around. we could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction. a portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle. it flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 ethibond sutures. the wounds were irrigated out with bacitracin and closed in a routine manner using two 3-0 vicryl for the galea and a 4-0 running monocryl for the scalp followed by mastisol and steri-strips. the patient was awakened and extubated having tolerated the procedure well without complications. it should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.

subjective: ,this patient presents to the office today for a checkup. he has several things to go over and discuss. first he is sick. he has been sick for a month intermittently, but over the last couple of weeks it is worse. he is having a lot of yellow phlegm when he coughs. it feels likes it is in his chest. he has been taking allegra-d intermittently, but he is almost out and he needs a refill. the second problem, his foot continues to breakout. it seems like it was getting a lot better and now it is bad again. he was diagnosed with tinea pedis previously, but he is about out of the nizoral cream. i see that he is starting to breakout again now that the weather is warmer and i think that is probably not a coincidence. he works in the flint and it is really hot where he works and it has been quite humid lately. the third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. he is interested in getting that frozen today. apparently, he tells me i froze a previous wart on him in the past and it went away. next, he is interested in getting some blood test done. he specifically mentions the blood test for his prostate, which i informed him is called the psa. he is 50 years old now. he will also be getting his cholesterol checked again because he has a history of high cholesterol. he made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. he says it is difficult to quit. he tells me he did quit chewing tobacco. i told him to keep trying to quit smoking. ,review of systems:, general: with this illness he has had no problems with fever. heent: some runny nose, more runny nose than congestion. respiratory: denies shortness of breath. skin: he has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today. at times it is itchy.,objective: , his weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16. general exam: the patient is nontoxic and in no acute distress. ears: tympanic membranes pearly gray bilaterally. mouth: no erythema, ulcers, vesicles, or exudate noted. neck is supple. no lymphadenopathy. lungs: clear to auscultation. no rales, rhonchi, or wheezing. cardiac: regular rate and rhythm without murmur. extremities: no edema, cyanosis, or clubbing. skin exam: i checked out the bottom of his right foot. he has peeling skin visible consistent with tinea pedis. on the anterior aspect of the right third finger there is a small little raised up area that i believe represents a wart. the size of this wart is approximately 3 mm in diameter.,assessment: ,1. upper respiratory tract infection, persistent.,2. tinea pedis.,3. wart on the finger.,4. hyperlipidemia.,5. tobacco abuse.,plan: , the patient is getting a refill on allegra-d. i am giving him a refill on the nizoral 2% cream that he should use to the foot area twice a day. i gave him instructions on how to keep the foot clean and dry because i think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work. his wart has been present for some time now and he would like to get it frozen. i offered him the liquid nitrogen treatment and he did agree to it. i used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart. he tolerated the procedure very well. i froze it once and i allowed for a 3 mm freeze zone. i gave him verbal wound care instructions after the procedure. lastly, when he is fasting i am going to send him to the lab with a slip, which i gave him today for a basic metabolic profile, cbc, fasting lipid profile, and a screening psa test. lastly, for the upper respiratory tract infection, i am giving him amoxicillin 500 mg three times a day for 10 days.

circumcision - neonatal,procedure:,: the procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. she is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. the infant was placed on the papoose board. the external genitalia were prepped with betadine. a penile block was performed with a 30-gauge needle and 1.5 ml of nesacaine without epinephrine.,next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis. the incision was made. next, all the adhesions of the inner preputial skin were broken down. the appropriate size bell was obtained and placed over the glans penis. the gomco clamp was then configured, and the foreskin was pulled through the opening of the gomco. the bell was then placed and tightened down. prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum. a blade was used to incise circumferentially around the bell. the bell was removed. there was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,vaseline gauze was then placed. the little boy was given back to his mom.,plan:, they have a new baby checkup in the near future with their primary care physician. i will see them back on a p.r.n. basis if there are any problems with the circumcision.

preoperative diagnoses:,1. chronic pelvic pain.,2. dysmenorrhea.,3. dyspareunia.,4. endometriosis.,5. enlarged uterus.,6. menorrhagia.,postoperative diagnoses:,1. chronic pelvic pain.,2. dysmenorrhea.,3. dyspareunia.,4. endometriosis.,5. enlarged uterus.,6. menorrhagia.,procedure: , total abdominal hysterectomy and bilateral salpingo-oophorectomy.,estimated blood loss: , less than 100 ml.,drains: , foley.,anesthesia:, general.,this 28-year-old white female who presented to undergo tah-bso secondary to chronic pelvic pain and a diagnosis of endometriosis.,at the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube. all endometriosis had been identified laparoscopically from a previous surgery. at the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,description of procedure: , the patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department. the patient was then prepped and draped in the usual fashion for a low transverse incision. approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision. this was extended down to the level of the fascia. the fascia was nicked in the center and extended in a transverse fashion. the edges of the fascia were grasped with kocher. both blunt and sharp dissection both caudally and cephalic was then completed consistent with pfannenstiel technique. the abdominal rectus muscle was divided in the midline and extended in a vertical fashion. perineum was entered at the high point and extended in a vertical fashion as well. an o'connor-o'sullivan retractor was put in place on either side. a bladder blade was put in place as well. uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade. the bladder flap was released with metzenbaum scissors and then dissected away caudally. endogia were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium endoclip. two heaney were placed on either side of the uterus at the level of cardinal ligaments. these were sharply incised and both pedicles were tied off with 1 vicryl suture. two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault. a long sharp knife was used to transect the uterus at the level of merz forceps and the uterus and cervix were removed intact. from there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches. betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 vicryl was used to re-approximate the edges with a second layer used to reinforce the first. bladder flap was created with the use of 3-0 vicryl and gelfoam was placed underneath. the endogia was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips. the entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity. once this was completed, gelfoam was placed into the cul-de-sac and the o'connor-o'sullivan retractor was removed as well as all the wet lap pack. edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle. the edges of the fascia were grasped at both corners and a continuous locking stitch of 1 vicryl was used to re-approximate the fascia with overlapping in the center. the subcutaneous tissue was irrigated. cautery was used to create adequate hemostasis and 3-0 vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples. sterile dressing was applied and betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood. the patient was taken to recovery room in stable condition. instrument count, needle count, and sponge counts were all correct.

general evaluation: ,twin b,fetal cardiac activity: normal at 166 bpm,fetal lie: longitudinal, to the maternal right.,fetal presentation: cephalic.,placenta: fused, posterior placenta, grade i to ii.,uterus: normal,cervix: closed.,adnexa: not seen,amniotic fluid: afi 5.5cm in a single ap pocket.,biometry:,bpd: 7.9cm consistent with 31weeks, 5 days gestation,hc: 31.1cm consistent with 33 weeks, 3 days gestation,ac: 30.0cm consistent with 34 weeks, 0 days gestation,fl:

preoperative diagnoses: , history of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,postoperative diagnoses: , history of compartment syndrome, right lower extremity, status post 4 compartments fasciotomy, to do incision for compartment fasciotomy.,operations:,1. wound debridement x2, including skin, subcutaneous, and muscle.,2. insertion of tissue expander to the medial wound.,3. insertion of tissue expander to the lateral wound.,complications: , none.,tourniquet: , none.,anesthesia: ,general.,indications: , this patient developed a compartment syndrome. she underwent 4 compartment fasciotomy with dual incision on medial and lateral aspect of the right lower leg. she was doing very well and was obviously improving.,the swelling was reduced. a compartment pressure had obviously improved based on examination. she was therefore indicated for placement of tissue expander for ventral wound closure. the risks of procedure as well as alternatives of this procedure were discussed at length with the patient and he understood them well. risks and benefits were all discussed, risk of bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgery, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. she understood them well. all questions were answered, and she signed the consent for the procedure as described.,description of the procedure:, the patient was placed on the operating table and general anesthesia was achieved. the medial wound was noted to be approximately 10.5 cm in length x 4 cm. the lateral wound was noted in approximately 14 cm in length x 5 x 5 cm in width. both wounds were then thoroughly debrided. the debridement of both wounds included skin and subcutaneous tissue and nonviable muscle portion. this involve very small portion of muscle as well as skin edge and the subcutaneous tissue did require debridement on both sides. at this point adequate debridement was performed and healthy tissue did appear to be present. initially on the medial wound i did place the dermaclose rc continuous external tissue expander. on the medial wound the 5 skin anchors were placed on each side of the wound and separated appropriately. i then did place the line loop from the tension controller in a lace like manner through the skin anchors and the tension controller was attached to the middle anchor. i then did place adequate tension on the sutures. continued tension will be noted after engaging the tension controller. at this point i performed the similar procedure to the lateral wound. the skin anchors were placed separately and appropriately on either side of the skin margin. the line loop from the tension controller was placed in lace like manner through the skin anchors. the tension controller was then attached to the mid anchor and appropriate tension was applied.,it must be noted i did undermine the skin edges both sides of flap from both incision site prior to placement of the skin anchor and adequate mobilization was obtained. adequate tension was placed in this region. a non thick dressing was then applied to the open-wound region and sterile dressing was then applied. no complications were encountered throughout the procedure and the patient tolerated the procedure well. the patient was taken to recovery room in stable condition.

preoperative diagnosis: , morbid obesity. ,postoperative diagnosis: , morbid obesity. ,procedure:, laparoscopic roux-en-y gastric bypass, antecolic, antegastric with 25-mm eea anastamosis, esophagogastroduodenoscopy. ,anesthesia: , general with endotracheal intubation. ,indications for procedure: , this is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs. the patient has now begun to have comorbidities related to the obesity. the patient has attended our bariatric seminar and met with our dietician and psychologist. the patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,procedure in detail: , the risks and benefits were explained to the patient. consent was obtained. the patient was taken to the operating room and placed supine on the operating room table. general anesthesia was administered with endotracheal intubation. a foley catheter was placed for bladder decompression. all pressure points were carefully padded, and sequential compression devices were placed on the legs. the abdomen was prepped and draped in standard, sterile, surgical fashion. marcaine was injected into the umbilicus.

chief complaint:, right hydronephrosis.,history of present illness: , the patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. she is scheduled to undergo mastectomy in two weeks. in september 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. again, she is scheduled for mastectomy in two weeks. she underwent a recent pet scan for dr. x, which revealed marked hydronephrosis on the right possibly related to right upj obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. there was no dilation of the right ureter noted. urinalysis today is microscopically negative.,past medical history: , uterine cancer, mesothelioma, breast cancer, diabetes, hypertension.,past surgical history: , lumpectomy, hysterectomy.,medications:, diovan hct 80/12.5 mg daily, metformin 500 mg daily.,allergies:, none.,family history: , noncontributory.,social history:, she is retired. does not smoke or drink.,review of systems:, i have reviewed his review of systems sheet and it is on the chart.,physical examination:, please see the physical exam sheet i completed. abdomen is soft, nontender, nondistended, no palpable masses, no cva tenderness.,impression and plan: , marked right hydronephrosis without hydruria. she believes she had a ct scan of the abdomen and pelvis at hospital in 2005. i will try to obtain the report to see if the right kidney was evaluated at that time. she will need evaluation with an ivp and renal scan to determine the point of obstruction and renal function of the right kidney. she is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. she will call us back to schedule the x-rays. she understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. there is also a question of a stone present in the kidney. she voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests.

subjective:, this is an 11-year-old female who comes in for two different things. 1. she was seen by the allergist. no allergies present, so she stopped her allegra, but she is still real congested and does a lot of snorting. they do not notice a lot of snoring at night though, but she seems to be always like that. 2. on her right great toe, she has got some redness and erythema. her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,past medical history:, otherwise reviewed and noted.,current medications:, none.,allergies to medicines:, none.,family social history:, everyone else is healthy at home.,review of systems:, she has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. review of systems is otherwise negative.,physical examination:,general: well-developed female, in no acute distress, afebrile.,heent: sclerae and conjunctivae clear. extraocular muscles intact. tms clear. nares patent. a little bit of swelling of the turbinates on the left. oropharynx is essentially clear. mucous membranes are moist.,neck: no lymphadenopathy.,chest: clear.,abdomen: positive bowel sounds and soft.,dermatologic: she has got redness along the lateral portion of her right great toe, but no bleeding or oozing. some dryness of her skin. her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,assessment:,1. history of congestion, possibly enlarged adenoids, or just her anatomy.,2. ingrown toenail, but slowly resolving on its own.,plan:,1. for the congestion, we will have ent evaluate. appointment has been made with dr. xyz for in a couple of days.,2. i told her just neosporin for her toe, letting the toenail grow out longer. call if there are problems.

exam:, echocardiogram.,interpretation: , echocardiogram was performed including 2-d and m-mode imaging, doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in m-mode. cardiac chamber dimensions, left atrial enlargement 4.4 cm. left ventricle, right ventricle, and right atrium are grossly normal. lv wall thickness and wall motion appeared normal. lv ejection fraction is estimated at 65%. aortic root and cardiac valves appeared normal. no evidence of pericardial effusion. no evidence of intracardiac mass or thrombus. doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal. there is mild tricuspid regurgitation. calculated pulmonary systolic pressure 42 mmhg.,echocardiographic diagnoses:,1. lv ejection fraction, estimated at 65%.,2. mild left atrial enlargement.,3. mild tricuspid regurgitation.,4. mildly elevated pulmonary systolic pressure.

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

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

cc:, headache,hx: ,37 y/o rhf presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. the headachese were dull to throbbing in character. she was initially treated with parafon-forte for tension type headaches, but the pain did not resolve. she subsequently underwent hct in early 12/90 which revealed a right frontal mass lesion.,pmh: ,1)s/p tonsillectomy. 2)s/p elective abortion.,fhx:, mother with breast ca, ma with "bone cancer." aodm both sides of family.,shx: ,denied tobacco or illicit drug use. rarely consumes etoh. married with 2 teenage children.,exam: ,vital signs unremarkable.,ms: alert and oriented to person, place, time. lucid thought process per nsg note.,cn: unremarkable.,motor: full strength with normal muscle bulk and tone.,sensory: unremarkable.,coordination: unremarkable.,station/gait: unremarkable.,reflexes: unremarkable.,gen. exam: unremarkable.,course:, mri brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. there is apparent tumor extension into the corpus callosum across the midline. tumor extension is also suggested in the anterior limb of the interanl capsule on the right. there is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. the mri findings are most consistent with glioblastoma.,the patient underwent right frontal lobectomy. the pathological diagnosis was xanthomatous astrocytoma. the literature at the time was not clear as to optimal treatment protocol. people have survived as long as 25 years after diagnosis with this type of tumor. xrt was deferred until 11/91 when an mri and pet scan suggested extension of the tumor. she then received 5580 cgy of xrt in divided segments. she developed olfactory auras shortly after lobectomy at was treated with pb with subsequent improvement. she was treated with bcnu chemotherapy protocol in 1992.

history of present illness: , the patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend. the patient has a long history of psychological disorders. as per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in abc medical center. the patient was evaluated in the emergency room. the initial cardiac workup was negative. the patient was admitted to telemetry unit for further evaluation. in the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine. the patient's ekg in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,past medical history: , as mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, chf, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer. none of the details of these are available.,past surgical history: , significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,current medications at home: , included dilantin 400 mg daily, klonopin 2 mg 3 times a day, elavil 300 mg at night, nitroglycerin sublingual p.r.n., thorazine 300 mg 3 times a day, neurontin 800 mg 4 times a day, and phenergan 25 mg as tolerated.,ob history: , her last menstrual period was 6/3/2009. the patient is admitting to having a recent abortion done. she is not too sure whether the abortion was completed or not, has not had a followup with her ob/gyn.,family history: ,noncontributory.,social history: ,she lives with her boyfriend. the patient has history of tobacco abuse as well as multiple illicit drug abuse.,review of systems: as mentioned above.,physical examination:,general: she is alert, awake, and oriented.,vital signs: her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,heent: shows head is atraumatic. pupils are round and reactive to light. extraocular muscles are intact. no oropharyngeal lesions noted.,neck: supple, no jv distention, no carotid bruits, and no lymphadenopathy.,lungs: clear to auscultation bilaterally.,cardiac: reveals regular rate and rhythm.,abdomen: soft, nontender, nondistended. bowel sounds are normally present.,lower extremities: shows no edema. distal pulses are 2+.,neurological: grossly nonfocal.,laboratory data: , the database that is available at this point of time, wbc count is normal, hemoglobin and hematocrit are normal. sodium, potassium, chloride, glucose, bicarbonate, bun and creatinine, and liver function tests are normal. the patient's 3 sets of cardiac enzymes including troponin-i, cpk-mb, and myoglobulin have been normal. ekg is normal, sinus rhythm without any acute st-t wave changes. as mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana. the patient also had a head ct done in the emergency room, which was fairly unremarkable. the patient's beta-hcg level was marginally elevated at about 48.,assessment and evaluation:,1. chest pains, appear to be completely noncardiac. the patient does seem to have a psychosomatic component to her chest pain. there is no evidence of acute coronary syndrome or unstable angina at this point of time.,2. possible early pregnancy. the patient's case was discussed with ob/gyn on-call over the phone. some of the medications have to be held secondary to potential danger. the patient will follow up on an outpatient basis with her primary ob/gyn as well as pcp for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3. migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control. again, this is an outpatient diagnosis. the patient will follow up with her pcp for control of migraine headache.,overall prognosis is too soon to predict.,the plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.

preoperative diagnosis: , patellar tendon retinaculum ruptures, right knee.,postoperative diagnosis: , patellar tendon retinaculum ruptures, right knee.,procedure performed: , patellar tendon and medial and lateral retinaculum repair, right knee.,specifications: ,intraoperative procedure done at inpatient operative suite, room #2 of abcd hospital. this was done under subarachnoid block anesthetic in supine position.,history and gross findings: , the patient is a 45-year-old african-american male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention. he did this while playing basketball.,he had a massive deficit at the inferior pole of his patella on exam. once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum. minimal cartilaginous pieces were at the patellar tendon. he had grade ii changes to his femoral sulcus as well as grade i-ii changes to the undersurface of the patella.,operative procedure: , the patient was laid supine on the operative table receiving a subarachnoid block anesthetic by anesthesia department. a thigh high tourniquet was placed. he is prepped and draped in the usual sterile manner. limb was elevated, exsanguinated and tourniquet placed at 325 mmhg for approximately 30 to 40 minutes. straight incision is carried down through skin and subcutaneous tissue anteriorly. hemostasis was controlled via electrocoagulation. patellar tendon was isolated along with the patella itself.,a 6 mm dacron tape x2 was placed with a modified kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape. the inferior pole was freshened up. drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer. this was tied over the bony bridge superiorly. there was excellent reduction of the tendon to the patella. interrupted running #1-vicryl suture was utilized for over silk. a running #2-0 vicryl for synovial closure medial and laterally as well as #1-vicryl medial and lateral retinaculum. there was excellent repair. copious irrigation was carried out. tourniquet was dropped and hemostasis controlled via electrocoagulation. interrupted #2-0 vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin. adaptic, 4 x 4s, abds, and sterile webril were placed for compression dressing. digits were warm and no brawny pulses present at the end of the case. the patient's leg was placed in a don-joy brace 0 to 20 degrees of flexion. he will leave this until seen in the office.,expected surgical prognosis on this patient is fair.

subjective: , the patient is admitted for shortness of breath, continues to do fairly well. the patient has chronic atrial fibrillation, on anticoagulation, inr of 1.72. the patient did undergo echocardiogram, which shows aortic stenosis, severe. the patient does have an outside cardiologist. i understand she was scheduled to undergo workup in this regard.,physical examination,vital signs: pulse of 78 and blood pressure 130/60.,lungs: clear.,heart: a soft systolic murmur in the aortic area.,abdomen: soft and nontender.,extremities: no edema.,impression:,1. status shortness of breath responding well to medical management.,2. atrial fibrillation, chronic, on anticoagulation.,3. aortic stenosis.,recommendations:,1. continue medications as above.,2. the patient would like to follow with her cardiologist regarding aortic stenosis. she may need a surgical intervention in this regard, which i explained to her. the patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,in the interim, if she changes her mind or if she has any concerns, i have requested to call me back.

preoperative diagnoses:,1. intrauterine pregnancy at 39 and 1/7th weeks.,2. previous cesarean section, refuses trial of labor.,3. fibroid uterus.,4. oligohydramnios.,5. nonreassuring fetal heart tones.,postoperative diagnoses:,1. intrauterine pregnancy at 39 and 1/7th weeks.,2. previous cesarean section, refuses trial of labor.,3. fibroid uterus.,4. oligohydramnios.,5. nonreassuring fetal heart tones.,procedure performed:, repeat low-transverse cesarean section via pfannenstiel incision.,anesthesia:, general.,complications:, none.,estimated blood loss:, 1200 cc.,fluids:, 2700 cc.,urine:, 400 cc clear at the end of the procedure.,drains: , foley catheter.,specimens: ,placenta, cord gases and cord blood.,indications: ,the patient is a g5 p1 caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to abcd hospital complaining of contractions. she was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and afof of approximately 40 mm. a decision was made to take her for a c-section early.,findings: , the patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally. there was a live male infant in the roa position with apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,procedure: , prior to the procedure, an informed consent was obtained. the patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery. she states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this. after informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with astramorph was administered. she was then prepped and draped in the normal sterile fashion. once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered. once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife. the fascia was incised in the midline with a second knife. this incision was then extended laterally in both directions with the mayo scissors. the superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using ochsner clamps. it was then dissected in the midline with mayo scissors. the inferior aspect of this incision was then addressed in a similar manner. the rectus muscles were then separated in the midline with a hemostat. the rectus muscles were separated further in the midline with mayo scissors superiorly and inferiorly. next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the metzenbaum scissors. this incision was extended inferiorly with the metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly. next, the bladder blade was placed. the vesicouterine peritoneum was identified, tenting up with allis clamps and entered sharply with the metzenbaum scissors. this incision was extended laterally in both directions and a bladder flap was created digitally. the bladder blade was then reinserted. next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife. next, the uterine incision was extended laterally in both directions with the banded scissors. next, the infant's head and body were delivered without difficulty. there was multiple section on the abdomen. the cord was clamped and cut. section of cord was collected for gases and the cord blood was collected. next, the placenta was manually extracted. the uterus was exteriorized and cleared of all clots and debris. the edges of the uterine incision were then identified with allis _______ clamps. the uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis. one figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid. after several minutes of observation, the hematoma was seem to be non-expanding. the uterus was replaced in the abdomen. the uterine incision was reexamined and seem to be continuing to be hemostatic. the pelvic gutters were then cleared of all clots and debris. the vesicouterine peritoneum was then reapproximated with #3-0 vicryl in a running fashion. the peritoneum was then closed with #0 vicryl in a running fashion. the rectus muscles reapproximated with #0 vicryl in a single interrupted stitch. the fascia was closed with #0 vicryl in a running locked fashion and the skin was closed with staples. the patient tolerated the procedure well. sponge, lap, and needle counts were correct x3. the patient was then taken to recovery in stable condition and she will be followed for immediate postoperative course in the hospital.

preoperative diagnoses: , nonhealing decubitus ulcer, left ischial region? osteomyelitis, paraplegia, and history of spina bifida.,postoperative diagnoses: , nonhealing decubitus ulcer, left ischial region? osteomyelitis, paraplegia, and history of spina bifida.,procedure performed: ,debridement left ischial ulcer.,anesthesia: ,local mac.,indications:, this is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic. the patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep. it appears to be right down to the bone. mri shows findings suggestive of osteomyelitis. the patient is being brought to operating room for debridement of this ulcer. procedure, indication, and risks were explained to the patient. consent obtained.,procedure in detail: ,the patient was put in right lateral position and left buttock and ischial region was prepped and draped. examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer. this was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base. the ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,i did not rongeur the bone. the deeper portion of the excised tissue was also sent for tissue cultures. hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated kerlix. sterile dressing was applied. the patient transferred to recovery room in stable condition.

procedures performed:, colonoscopy.,indications:, renewed symptoms likely consistent with active flare of inflammatory bowel disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,procedure: , informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives. risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications. vital signs were monitored by blood pressure, heart rate, and oxygen saturation. supplemental o2 given. specifics discussed. preprocedure physical exam performed. stable vital signs. lungs clear. cardiac exam showed regular rhythm. abdomen soft. her past history, her past workup, her past visitation with me for inflammatory bowel disease, well responsive to sulfasalazine reviewed. she currently has a flare and is not responding, therefore, likely may require steroid taper. at the same token, her symptoms are mild. she has rectal bleeding, essentially only some rusty stools. there is not significant diarrhea, just some lower stools. no significant pain. therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed. past history reviewed. specifics of workup, need for followup, and similar discussed. all questions answered.,a normal digital rectal examination was performed. the pcf-160 al was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice. all mucosal aspects thoroughly inspected, including a retroflexed examination. withdrawal time was greater than six minutes. unfortunately, the terminal ileum could not be intubated despite multiple attempts.,findings were those of a normal cecum, right colon, transverse colon, descending colon. a small cecal polyp was noted, this was biopsy-removed, placed in bottle #1. random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3. there was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4. there was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with crohn disease, given the relative sparing of the sigmoid colon and junk lesion. retroflexed showed hemorrhoidal disease. scope was then withdrawn, patient left in good condition. ,impression:, active flare of inflammatory bowel disease, question of crohn disease.,plan: , i will have the patient follow up with me, will follow up on histology, follow up on the polyps. she will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job. if not, she may be started on immune suppressive medication, such as azathioprine, or similar. all of this has been reviewed with the patient. all questions answered.

chief complaint: , the patient is here for followup visit and chemotherapy.,diagnoses:,1. posttransplant lymphoproliferative disorder.,2. chronic renal insufficiency.,3. squamous cell carcinoma of the skin.,4. anemia secondary to chronic renal insufficiency and chemotherapy.,5. hypertension.,history of present illness: , a 51-year-old white male diagnosed with ptld in latter half of 2007. he presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia. he did not seek medical attention immediately. he was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma. he was discussed at the hematopathology conference. chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started. first cycle of chemotherapy was complicated by sepsis despite growth factor support. he also appeared to have become disoriented either secondary to sepsis or steroid therapy.,the patient has received 5 cycles of chemotherapy to date. he did not keep his appointment for a pet scan after 3 cycles because he was not feeling well. his therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,the patient is here for the sixth and final cycle of chemotherapy. he states he feels well. he denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue. he denies any tingling or numbness in his fingers. review of systems is otherwise entirely negative.,performance status on the ecog scale is 1.,physical examination:,vital signs: he is afebrile. blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit. there is mild pallor noted. there is no icterus, adenopathy or petechiae noted. chest: clear to auscultation. cardiovascular: s1 and s2 normal with regular rate and rhythm. systolic flow murmur is best heard in the pulmonary area. abdomen: soft and nontender with no organomegaly. renal transplant is noted in the right lower quadrant with a scar present. extremities: reveal no edema.,laboratory data: , cbc from today shows white count of 9.6 with a normal differential, anc of 7400, hemoglobin 8.9, hematocrit 26.5 with an mcv of 109, and platelet count of 220,000.,assessment and plan:,1. diffuse large b-cell lymphoma following transplantation. the patient is to receive his sixth and final cycle of chemotherapy today. pet scan has been ordered to be done within 2 weeks. he will see me back for the visit in 3 weeks with cbc, cmp, and ldh.,2. chronic renal insufficiency.,3. anemia secondary to chronic renal failure and chemotherapy. he is to continue on his regimen of growth factor support.,4. hypertension. this is elevated today because he held his meds because he is getting rituximab other than that this is well controlled. his cmp is pending from today.,5. squamous cell carcinoma of the skin. the scalp is well healed. he still has an open wound on the right posterior aspect of his trunk. this has no active drainage, but it is yet to heal. this probably will heal by secondary intention once chemotherapy is finished. prescription for prednisone as part of his chemotherapy has been given to him.

preoperative diagnoses:,1. right spontaneous pneumothorax secondary to barometric trauma.,2. respiratory failure.,3. pneumonia with sepsis.,postoperative diagnoses:,1. right spontaneous pneumothorax secondary to barometric trauma.,2. respiratory failure.,3. pneumonia with sepsis.,informed consent: , not obtained. this patient is obtunded, intubated, and septic. this is an emergent procedure with 2-physician emergency consent signed and on the chart.,procedure: , the patient's right chest was prepped and draped in sterile fashion. the site of insertion was anesthetized with 1% xylocaine, and an incision was made. blunt dissection was carried out 2 intercostal spaces above the initial incision site. the chest wall was opened, and a 32-french chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly. the chest tube was placed.,a postoperative chest x-ray is pending at this time.,the patient tolerated the procedure well and was taken to the recovery room in stable condition.,estimated blood loss:, 10 ml,complications:, none.,sponge count: , correct x2.

preoperative diagnosis:, right frontotemporal chronic subacute subdural hematoma.,postoperative diagnosis:, right frontotemporal chronic subacute subdural hematoma.,title of the operation: , right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,assistant: , none.,indications: , the patient is a 75-year-old man with a 6-week history of decline following a head injury. he was rendered unconscious by the head injury. he underwent an extensive syncopal workup in mississippi. this workup was negative. the patient does indeed have a heart pacemaker. the patient was admitted to abcd three days ago and yesterday underwent a ct scan, which showed a large appearance of subdural hematoma. there is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes. i decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity. the patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,description of procedure: ,the patient was brought to the operating room where general and endotracheal anesthesia was obtained. the head was turned over to the left side and was supported on a cushion. there was a roll beneath the right shoulder. the right calvarium was shaved and prepared in the usual manner with betadine-soaked scrub followed by betadine paint. markings were applied. sterile drapes were applied. a linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline. sharp dissection was carried down into subcutaneous tissue and bovie electrocautery was used to divide the galea and the temporalis muscle and fascia. weitlaner retractors were inserted. a single bur hole was placed underneath the temporalis muscle. i placed the craniotomy a bit low in order to have better cosmesis. a cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm. the bone was set aside. the dura was clearly discolored and very tense. the dura was opened in a cruciate fashion with a #15 blade. there was immediate flow of a thin motor oil fluid under high pressure. literally the fluid shot out several inches with the first nick in the membranous cavity. the dura was reflected back and biopsy of the membranes was taken and sent for permanent section. the margins of the membrane were coagulated. the microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery. the wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none. the dura was then closed in a watertight fashion using running locking 4-0 nurolon. tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the lorenz plating system. the wound was irrigated thoroughly once more and was closed in layers. muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 vicryl. finally, the skin was closed with running locking 3-0 nylon.,estimated blood loss for the case was less than 30 ml. sponge and needle counts were correct.,findings: , chronic subdural hematoma with multiple septations and thickened subdural membrane.,i might add that the arachnoid was not violated at all during this procedure. also, it was noted that there was no subarachnoid blood but only subdural blood.

diagnoses:,1. juvenile myoclonic epilepsy.,2. recent generalized tonic-clonic seizure.,medications:,1. lamictal 250 mg b.i.d.,2. depo-provera.,interim history: , the patient returns for followup. since last consultation she has tolerated lamictal well, but she has had a recurrence of her myoclonic jerking. she has not had a generalized seizure. she is very concerned that this will occur. most of the myoclonus is in the mornings. recent eeg did show polyspike and slow wave complexes bilaterally, more prominent on the left. she states that she has been very compliant with the medications and is getting a good amount of sleep. she continues to drive.,social history and review of systems are discussed above and documented on the chart.,physical examination: , vital signs are normal. pupils are equal and reactive to light. extraocular movements are intact. there is no nystagmus. visual fields are full. demeanor is normal. facial sensation and symmetry is normal. no myoclonic jerks noted during this examination. no myoclonic jerks provoked by tapping on her upper extremity muscles. negative orbit. deep tendon reflexes are 2 and symmetric. gait is normal. tandem gait is normal. romberg negative.,impression and plan:, recurrence of early morning myoclonus despite high levels of lamictal. she is tolerating the medication well and has not had a generalized tonic-clonic seizure. she is concerned that this is a precursor for another generalized seizure. she states that she is compliant with her medications and has had a normal sleep-wake cycle.,looking back through her notes, she initially responded very well to keppra, but did have a breakthrough seizure on keppra. this was thought secondary to severe insomnia when her baby was very young. because she tolerated the medication well and it was at least partially affective, i have recommended adding keppra 500 mg b.i.d. side effect profile of this medication was discussed with the patient.,i will see in followup in three months.

reason for consultation:, chest pain.,history of present illness: , the patient is a 37-year-old gentleman admitted through emergency room. he presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. also, shortness of breath is noted without any diaphoresis. symptoms on and off for the last 3 to 4 days especially when he is under stress. no relation to exertional activity. no aggravating or relieving factors. his history is significant as mentioned below. his workup so far has been negative.,coronary risk factors:, no history of hypertension or diabetes mellitus. active smoker. cholesterol status, borderline elevated. no history of established coronary artery disease. family history positive.,family history: , his father died of coronary artery disease.,surgical history: , no major surgery except for prior cardiac catheterization.,medications at home:, includes pravastatin, paxil, and buspar.,allergies:, none.,social history: , active smoker. does not consume alcohol. no history of recreational drug use.,past medical history: , hyperlipidemia, smoking history, and chest pain. he has been, in october of last year, hospitalized. subsequently underwent cardiac catheterization. the left system was normal. there was a question of a right coronary artery lesion, which was thought to be spasm. subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. the patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. no relation to exertional activity.,review of systems:,constitutional: no history of fever, rigors, or chills.,heent: no history of cataract, blurring vision, or glaucoma.,cardiovascular: as above.,respiratory: shortness of breath. no pneumonia or valley fever.,gastrointestinal: no epigastric discomfort, hematemesis, or melena.,urological: no frequency or urgency.,musculoskeletal: no arthritis or muscle weakness.,cns: no tia. no cva. no seizure disorder.,endocrine: nonsignificant.,hematological: nonsignificant.,physical examination:,vital signs: pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute.,heent: head is atraumatic and normocephalic. neck veins flat.,lungs: clear.,heart: s1 and s2, regular.,abdomen: soft and nontender.,extremities: no edema. pulses palpable. no clubbing or cyanosis.,cns: benign.,psychological: normal.,musculoskeletal: within normal limits.,diagnostic data: , ekg, normal sinus rhythm. chest x-ray unremarkable.,laboratory data: , first set of cardiac enzyme profile negative. h&h stable. bun and creatinine within normal limits.,impression:,1. chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.,2. hyperlipidemia.,3. negative ekg and cardiac enzyme profile.,recommendations:

preoperative diagnosis: , herniated nucleus pulposus c5-c6.,postoperative diagnosis: , herniated nucleus pulposus c5-c6.,procedure:, anterior cervical discectomy fusion c5-c6 followed by instrumentation c5-c6 with titanium dynamic plating system, aesculap. operating microscope was used for both illumination and magnification.,first assistant: , nurse practitioner.,procedure in detail: , the patient was placed in supine position. the neck was prepped and draped in the usual fashion for anterior discectomy and fusion. an incision was made midline to the anterior body of the sternocleidomastoid at c5-c6 level. the skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally. trachea and esophagus were retracted medially. after placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at c5 and c6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,we then cleaned out the disc at c5-c6 after incising the annulus fibrosis. we cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally. with this having been done, we then turned our attention with the operating microscope to the osteophytes. we drilled off the vertebral osteophytes at c5-c6, as well as the uncovertebral osteophytes. this was removed along with the posterior longitudinal ligament. after we had done this, the dural sac was opposed very nicely and both c6 nerve roots were thoroughly decompressed. the next step after the decompression of the thecal sac and both c6 nerve roots was the fusion. we observed that there was a ____________ in the posterior longitudinal ligament. there was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,the next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size. that was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,after we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,we then use the aesculap cervical titanium instrumentation with the 16-mm screws. after securing the c5-c6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a jackson-pratt drain in the prevertebral space brought out through a separate incision. the wound was closed with 2-0 vicryl for subcutaneous tissues and skin was closed with steri-strips. blood loss during the operation was less than 10 ml. no complications of the surgery. needle count, sponge count, and cottonoid count were correct.,

preoperative diagnosis: ,grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,postoperative diagnosis: , grade 1 compound fracture, right mid-shaft radius and ulna with complete displacement and shortening.,operations:,1. irrigation and debridement of skin subcutaneous tissues, muscle, and bone, right forearm.,2. open reduction, right both bone forearm fracture with placement of long-arm cast.,complications:, none.,tourniquet: , none.,estimated blood loss:, 25 ml.,anesthesia: , general.,indications: ,the patient suffered injury at which time he fell over a concrete bench. he landed mostly on the right arm. he noted some bleeding at the time of the injury and a small puncture wound. he was taken to the emergency room and diagnosed a compound both bone forearm fracture, and based on this, he was seen for malalignment.,he was indicated the above-noted procedure. this procedure as well as alternatives of this procedure was discussed at length with the patient's parents and they understood them well. risks and benefits were also discussed. risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain on full range of motion, risk of continued discomfort, risk of need for repeat debridement, risk of need for internal fixation, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed. they understood these well. all questions were answered and they signed the consent for procedure as described.,description of procedure: ,the patient was placed on the operating table and general anesthesia was achieved. the right forearm was inspected. there was noted to be a 3-mm puncture-type wound over the volar aspect of the forearm in the middle one-third overlying the radial one-half. there was bleeding in this region. no gross contamination was seen. at this point, under fluoroscopic control, i did attempt to see a fracture. i was unable to do the forearm under the close reduction techniques. at this point, the right upper extremity was then prepped and draped in the usual sterile manner. an incision was made through the puncture wound site extending this proximally and distally. there was noted to be some slight amount of nonviable tissue at the skin edge and debridement was required and performed. i also did perform a light debridement of the nonviable subcutaneous tissue, muscle, and small bony fragments were also removed. these were all completely debrided appropriately and then at this point, a thorough irrigation was performed of the radius, which i communicated through the puncture wound. both ends were clearly visualized, and thorough irrigation was performed using total of 6 l of antibiotic solution. all nonviable gross contaminated tissue was removed. at this point with the bones in direct visualization, i did reduce the bony ends to anatomic alignment with excellent bony approximation. proper alignment of tissue and angulation was confirmed.,at this point, under fluoroscopic control confirmed the radius and ulna in anatomic position, which will be completely displaced and shortened previously. the ulna was now also noted to be in anatomic alignment.,at this point, the region was thoroughly irrigated. hemostasis confirmed and closure then begun. the skin was reapproximated using 3-0 nylon suture. the visual puncture wound region was left open and this was intact with the depth of the wound down the bone using 1.5-inch nugauze with iodoform. sterile dressing applied and a long-arm cast with the forearm in neutral position was applied. x-ray with fluoroscopic evaluation was performed, which confirmed. they maintained excellent bony approximation and the anatomic alignment. the long-arm cast was then completely mature. no complications were encountered throughout the procedure. the patient tolerated the procedure well. the patient was then taken to the recovery room in stable condition.