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cc: ,sensory loss.,hx: ,25y/o rhf began experiencing pruritus in the rue, above the elbow and in the right scapular region, on 10/23/92. in addition she had paresthesias in the proximal ble and toes of the right foot. her symptoms resolved the following day. on 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. the sensory loss gradually progressed rostrally to the mid chest. she felt unsteady on her feet and had difficulty ambulating. in addition she also began to experience pain in the right scapular region. she denied any heat or cold intolerance, fatigue, weight loss.,meds:, none.,pmh:, unremarkable.,fhx: ,gf with cad, otherwise unremarkable.,shx:, married, unemployed. 2 children. patient was born and raised in iowa. denied any h/o tobacco/etoh/illicit drug use.,exam:, bp121/66 hr77 rr14 36.5c,ms: a&o to person, place and time. speech normal with logical lucid thought process.,cn: mild optic disk pallor os. no rapd. eom full and smooth. no ino. the rest of the cn exam was unremarkable.,motor: full strength throughout all extremities except for 5/4+ hip extensors. normal muscle tone and bulk.,sensory: decreased pp/lt below t4-5 on the left side down to the feet. decreased pp/lt/vib in ble (left worse than right). allodynic in rue.,coord: intact fnf, hks and ram, bilaterally.,station: no pronator drift. romberg's test not documented.,gait: unsteady wide-based. able to tt and hw. poor tw.,reflexes: 3/3 bue. hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ achilles with 3-4 beat nonsustained clonus. plantar responses were extensor on the right and flexor on the left.,gen. exam: unremarkable.,course:, cbc, gs, pt, ptt, esr, ft4, tsh, ana, vit b12, folate, vdrl and urinalysis were normal. mri t-spine, 10/27/92, was unremarkable. mri brain, 10/28/92, revealed multiple areas of abnormally increased signal on t2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. the appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, lumbar puncture revealed the following csf results: rbc 1, wbc 9 (8 lymphocytes, 1 histiocyte), glucose 55mg/dl, protein 46mg/dl (normal 15-45), csf igg 7.5mg/dl (normal 0.0-6.2), csf igg index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. beta-2 microglobulin was unremarkable. an abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. visual and brainstem auditory evoked potentials were normal. htlv-1 titers were negative. csf cultures and cytology were negative. she was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,she returned on 11/7/92 as her symptoms of rue dysesthesia, lower extremity paresthesia and weakness, all worsened. on 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. she also began having difficulty emptying her bladder. her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. she was oriented to place and time of day, but not to season, day of the week and she did not know who she was. she had a leftward gaze preference and right lower facial weakness. her rle was spastic with sustained ankle clonus. there was dysesthetic sensory perception in the rue. jaw jerk and glabellar sign were present.,mri brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. the right peritrigonal region is more prominent than on prior study. the left centrum semiovale lesion has less enhancement than previously. multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. the peritrigonal lesions on both sides have increased in size since the 10/92 mri. the findings were felt more consistent with demyelinating disease and less likely glioma. post-viral encephalitis, rapidly progressive demyelinating disease and tumor were in the differential diagnosis. lumbar puncture, 11/8/92, revealed: rbc 2, wbc 12 (12 lymphocytes), glucose 57, protein 51 (elevated), cytology and cultures were negative. hiv 1 titer was negative. urine drug screen, negative. a stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. she was treated with decadron 6mg iv qhours and cytoxan 0.75gm/m2 (1.25gm). on 12/3/92, she has a focal motor seizure with rhythmic jerking of the lue, loss of consciousness and rightward eye deviation. eeg revealed diffuse slowing with frequent right-sided sharp discharges. she was placed on dilantin. she became depressed.

history: , the patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with cpap, chocolate/caffeine ingestion and significant mental stress. despite repletion of her electrolytes and maintenance with diltiazem iv she has maintained atrial fibrillation. i have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure. after an in depth discussion of the procedure (please see my initial consultation for further details) i asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday. the patient declined. i invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,procedure note: , the appropriate time-out procedure was performed as per medical center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff. the patient participated actively in this. she received a total of 4 mg of versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect. she was placed in the supine position and hands free patches had previously been placed in the ap position and she received one synchronized cardioversion attempt after diltiazem drip had been turned off with successful resumption of normal sinus rhythm. this was confirmed on 12 lead ekg.,impression/plan: , successful resumption of normal sinus rhythm from recurrent atrial fibrillation. the patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with cpap and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress. she will be discharged on her usual robust av nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., diltiazem cd 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted. she will follow-up with her regular cardiologist, dr. x, for whom i am covering this weekend.,this was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.

clinical indications: , mrsa bacteremia, rule out endocarditis. the patient has aortic stenosis.,description of procedure: , the transesophageal echocardiogram was performed after getting verbal and a written consent signed. then a multiplane tee probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained. there were no complications. the patient's throat was numbed with cetacaine spray and iv sedation was achieved with versed and fentanyl.,findings:,1. aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp. the peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmhg and peak gradient 84 mmhg with calculated aortic valve area of 0.6 sq cm by planimetry.,2. mitral valve is calcified and thick. no vegetation seen. there is mild-to-moderate mr present. there is mild ai present also.,3. tricuspid valve and pulmonary valve are structurally normal.,4. there is a mild tr present.,5. there is no clot seen in the left atrial appendage. the velocity in the left atrial appendage was 0.6 m/sec.,6. intraatrial septum was intact. there is no clot or mass seen.,7. normal lv and rv systolic function.,8. there is thick raised calcified plaque seen in the thoracic aorta and arch.,summary:,1. there is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis. calculated aortic valve area was 0.6 sq. cm.,2. normal lv systolic function.,

preoperative diagnosis: , recurrent anterior dislocating left shoulder.,postoperative diagnosis:, recurrent anterior dislocating left shoulder.,procedure performed:, arthroscopic debridement of the left shoulder with attempted arthroscopic bankart repair followed by open bankart arthroplasty of the left shoulder.,procedure: ,the patient was taken to or #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area. the patient was positioned in the modified beachchair position utilizing the mayfield headrest. the left shoulder was propped posteriorly with a rolled towel. his head was secured to the mayfield headrest. the left shoulder and upper extremity were then prepped and draped in the usual manner. a posterior lateral port was made for _____ the arthroscopic cannula. the scope was introduced into the glenohumeral joint. there was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock. the labrum was adherent to the underlying capsule. the margin of the glenoid was frayed in this area. the biceps tendon was noted to be intact. the articular surface of the glenoid was fairly well preserved. the articular surface on the humeral head was intact; however, there was a large hill-sachs lesion on the posterolateral aspect of the humeral head. the rotator cuff was visualized and noted to be intact. the axillary pouch was visualized and it was free of injury. there were some cartilaginous fragments within the axillary pouch. attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum. utilizing the chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position. a second tack was then placed at about the 8 o'clock position. the labrum was then probed and was noted to be stable. with some general ranging of the shoulder, the tissue was pulled out from the tacks. an attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position. therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area. at this point, it was deemed that an open bankart arthroplasty was necessary. the arthroscopic instruments were removed. an anterior incision was made extending from just lateral of the coracoid down toward the axillary fold. the skin incision was taken down through the skin. subcutaneous tissues were then separated with the coag bovie to provide hemostasis. the deltopectoral fascia was identified. it was split at the deltopectoral interval and the deltoid was reflected laterally. the subdeltoid bursa was then removed with rongeurs. the conjoint tendon was identified. the deltoid and conjoint tendons were then retracted with a self-retaining retractor. the subscapularis tendon was identified. it was separated about a centimeter from its insertion, leaving the tissue to do sew later. the subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially. this allowed for visualization of the capsule. the capsule was split near the humeral head insertion leaving a tag for repair. it was then split longitudinally towards the glenoid at approximately 9 o'clock position. this provided visualization of the glenohumeral joint. the friable labral and capsular tissue was identified. the glenoid neck was already prepared for suturing, therefore, three mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock. the sutures were passed through the labral capsular tissue and tied securely. at this point, the anterior glenoid rim had been recreated. the joint was then copiously irrigated with gentamicin solution and suctioned dry. the capsule was then repaired with interrupted #1 vicryl suture and repaired back to its insertion site with #1 vicryl suture. this later was then copiously irrigated with gentamicin solution and suctioned dry. subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 vicryl suture. this later was then copiously irrigated as well and suctioned dry. the deltoid fascia was approximated with running #2-0 vicryl suture. subcutaneous tissues were approximated with interrupted #2-0 vicryl and the skin was approximated with a running #4-0 subcuticular vicryl followed by placement of steri-strips. 0.25% marcaine was placed in the subcutaneous area for postoperative analgesia. the patient was then placed in a shoulder immobilizer after a bulky dressing had been applied. the patient was then transferred to the recovery room in apparent satisfactory condition.

diagnoses:,1. disseminated intravascular coagulation.,2. streptococcal pneumonia with sepsis.,chief complaint: , unobtainable as the patient is intubated for respiratory failure.,current history of present illness: , this is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. at this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated d-dimer. at this time, i am being consulted for further evaluation and recommendations for treatment. the nurses report that she has actually improved clinically over the last 24 hours. bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. there is no prior history of coagulopathy.,past medical history: ,otherwise nondescript as is the past surgical history.,social history: ,there were possible illicit drugs. her family is present, and i have discussed her case with her mother and sister.,family history: ,otherwise noncontributory.,review of systems: , not otherwise pertinent.,physical examination:,general: she is a sedated, young black female in no acute distress, lying in bed intubated.,vital signs: she has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,heent: her sclerae showed conjunctival hemorrhage. there are no petechiae. her nasal vestibules are clear. oropharynx has et tube in place.,neck: no jugular venous pressure distention.,chest: coarse breath sounds bilaterally.,heart: regular rate and rhythm.,abdomen: soft and nontender with good bowel sounds. there was some oozing around the site of her central line.,extremities: no clubbing, cyanosis, or edema. there is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,laboratory studies: ,the dic parameters with a platelet count of approximately 50,000, inr of 2.4, normal ptt at this time, fibrinogen of 200, and a d-dimer of 13.,impression/plan: ,at this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. my recommendation for the patient is to continue factor replacement as you are. it seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. there is no indication at this point for xigris. however, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, i would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. i will repeat her laboratory studies in the morning and give more recommendations at that time.

admitting diagnosis: , kawasaki disease.,discharge diagnosis:, kawasaki disease, resolving.,hospital course:, this is a 14-month-old baby boy caucasian who came in with presumptive diagnosis of kawasaki with fever for more than 5 days and conjunctivitis, mild arthritis with edema, rash, resolving and with elevated neutrophils and thrombocytosis, elevated crp and esr. when he was sent to the hospital, he had a fever of 102. subsequently, the patient was evaluated and based on the criteria, he was started on high dose of aspirin and ivig. echocardiogram was also done, which was negative. ivig was done x1, and between 12 hours of ivig, he spiked fever again; it was repeated twice, and then after second ivig, he did not spike any more fever. today, his fever and his rash have completely resolved. he does not have any conjunctivitis and no redness of mucous membranes. he is more calm and quite and taking good p.o.; so with a very close followup and a cardiac followup, he will be sent home.,discharge activities:, ad-lib.,discharge diet: , po ad-lib.,discharge medications: , aspirin high dose 340 mg q.6h. for 1 day and then aspirin low dose 40 mg q.d. for 14 days and then prevacid also to prevent his gi from aspirin 15 mg p.o. once a day. he will be followed by his primary doctor in 2 to 3 days. cardiology for echo followup in 4 to 6 weeks and instructed not to give any vaccine in less than 11 months because of ivig, all the live virus vaccine, and if he gets any rashes, any fevers, should go to primary care doctor as soon as possible.

preoperative diagnoses: , coronal hypospadias with chordee and asthma.,postoperative diagnoses:, coronal hypospadias with chordee and asthma.,procedure: , hypospadias repair (tip) with tissue flap relocation and chordee release (nesbit tuck).,anesthetic: , general inhalational anesthetic with a caudal block.,fluids received: ,300 ml of crystalloid.,estimated blood loss: ,20 ml.,tubes/drains: ,an 8-french zaontz catheter.,indications for operation: ,the patient is a 17-month-old boy with hypospadias abnormality. the plan is for 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, a caudal block was placed. iv antibiotics were given. he was then placed in the supine position. the foreskin was retracted and cleansed. he was then sterilely prepped and draped. a stay stitch of 4-0 prolene was then placed on the glans. the urethra was calibrated with the lacrimal duct probes to an 8-french. we then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,we then used a 15-blade knife to circumscribe the penis around the coronal cuff. we then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis. the patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap. once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using iv grade saline injected the penis for an artifical erection. he was still noted to have chordee, so a midline incision through the buck fascia was made with a 15-blade knife and heineke-mikulicz closure using 5-0 prolene was then used for the chordee nesbit tuck. we repeated the artificial erection and the penis was straight. we then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them. using the curved iris scissors, we then also further mobilized the glanular wings. the 8-french zaontz was then placed while the tourniquet was still in place into the urethral plate. the upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 vicryl, and then using a running subcuticular closure, we closed the urethral plates over the zaontz catheter. we then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 vicryl. we then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 vicryl was used for that as well. 5-0 vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 vicryl were used to reconstitute the glans. interrupted sutures of 7-0 vicryl were used to approximate the urethral meatus to the glans. once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff. on the ventrum itself, we used horizontal mattress sutures to close the defect.,at the end of the procedure, the zaontz catheter was sutured into place with a 4-0 prolene suture, dermabond tissue adhesive, and surgicel was used as a dressing and a second layer of telfa and clear eye tape was then used to tape it into place. iv toradol was given at the procedure. the patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.

intensity-modulated radiation therapy,intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices. the treatment planning process requires at least 4 hours of physician time. the technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures. sequential ct scans are obtained and transferred to the treatment planning software. extensive analysis occurs. the target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected. in addition, organs at risk are outlined. doses are selected both for targets, as well as for organs at risk. associated dose constraints are placed. inverse treatment planning is then performed in conjunction with the physics staff. these are reviewed by the physician and ultimately performed only following approval by the physician. multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk. this is performed in hopes of minimizing associated complications. the physician delineates the treatment type, number of fractions and total volume. during the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance. in addition, specific qa is performed by the physics staff under the physician's direction.,in view of the above, the special procedure code 77470 is deemed appropriate.

female physical examination,eye: eyelids normal color, no edema. conjunctivae with no erythema, foreign body, or lacerations. sclerae normal white color, no jaundice. cornea clear without lesions. pupils equally responsive to light. iris normal color, no lesions. anterior chamber clear. lacrimal ducts normal. fundi clear.,ear: external ear has no erythema, edema, or lesions. ear canal unobstructed without edema, discharge, or lesions. tympanic membranes clear with normal light reflex. no middle ear effusions.,nose: external nose symmetrical. no skin lesions. nares open and free of lesions. turbinates normal color, size and shape. mucus clear. no internal lesions.,throat: no erythema or exudates. buccal mucosa clear. lips normal color without lesions. tongue normal shape and color without lesion. hard and soft palate normal color without lesions. teeth show no remarkable features. no adenopathy. tonsils normal shape and size. uvula normal shape and color.,neck: skin has no lesions. neck symmetrical. no adenopathy, thyromegaly, or masses. normal range of motion, nontender. trachea midline.,chest: symmetrical. clear to auscultation bilaterally. no wheezing, rales or rhonchi. chest nontender. normal lung excursion. no accessory muscle use.,cardiovascular: heart has regular rate and rhythm with no s3 or s4. heart rate is normal.,abdominal: soft, nontender, nondistended, bowel sounds present. no hepatomegaly, splenomegaly, masses, or bruits.,genital: labia majora normal shape without erythema or lesions. labia minora normal shape without erythema or lesions. clitoris normal shape and contour. vaginal mucosa normal color without lesions. no significant discharge. cervix normal shape and parity without lesions. ovaries normal shape and contour. no pelvic masses. uterus normal shape and contour. no external hemorrhoids.,musculoskeletal: normal strength all muscle groups. normal range of motion all joints. no joint effusions. joints normal shape and contour. no muscle masses.,foot: no erythema. no edema. normal range of motion all joints in the foot. nontender. no pain with inversion, eversion, plantar or dorsiflexion.,ankle: anterior and posterior drawer test negative. no pain with inversion, eversion, dorsiflexion, or plantar flexion. collateral ligaments intact. no joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,knee: normal range of motion. no joint effusion, erythema, nontender. anterior and posterior drawer tests negative. lachman's test negative. collateral ligaments intact. bursas nontender without edema.,wrist: normal range of motion. no edema or effusion, nontender. negative tinel and phalen tests. normal strength all muscle groups.,elbow: normal range of motion. no joint effusion or erythema. normal strength all muscle groups. nontender. olecranon bursa flat and nontender, no edema. normal supination and pronation of forearm. no crepitus.,hip: negative swinging test. trochanteric bursa nontender. normal range of motion. normal strength all muscle groups. no pain with eversion and inversion. no crepitus. normal gait.,psychiatric: alert and oriented times four. no delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality. affect is appropriate. no psychomotor slowing or agitation. eye contact is appropriate.

preoperative diagnosis: , visually significant cataract, left eye.,postoperative diagnosis: , visually significant cataract, left eye.,anesthesia: , topical/mac.,procedure: , phacoemulsification cataract extraction with intraocular lens implantation, left eye (alcon acrysof, sn60at, 23.0 d, serial #***).,complications: , none.,indications for surgery: ,the patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye. she was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,procedure in detail: ,the patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart. they were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established. mac anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops. the patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,two stab-incision paracenteses were made in the cornea using the mvr blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia. the anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome. a continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome. the lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (bss) on a chang cannula until it rotated freely.,the phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves. each half was further subdivided with chopping and removed with phacoemulsification. the remaining cortical material was removed with the irrigation and aspiration (i&a) handpiece. the capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty. the remaining viscoelastic was removed with the i&a handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with bss. the corneal wounds were hydrated and verified to be water-tight. antibiotic ointment was placed, followed by a patch and shield. the patient was transported to the pacu in good/stable condition. there were no complications. followup is scheduled for tomorrow morning in the eye clinic.,a single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.

chief complaint: , followup of hospital discharge for guillain-barre syndrome.,history of present illness: , this is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late june of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. she was admitted to the hospital. the mri showed only an old right basal ganglion infarct. she subsequently had a lumbar puncture, which showed increased protein, and an emg/nerve conduction study performed by dr. x on july 3rd, showed early signs of aidp. the patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. her vital capacities were normal during the hospitalization. her chest x-ray was negative for any acute process. she was discharged to rehab from july 12, 2006 to july 20, 2006. she made some progress in which she notes that her walking is definitely better. however, she notes that she still has some problems with eye movement and her vision. this is possibly her main problem. she also reports tightness and pain in her mid back.,review of systems:, documented in the clinic note. the patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,past medical history:,1. hypertension.,2. diabetes mellitus.,3. stroke involving the right basal ganglion.,4. guillain-barre syndrome diagnosed in june of 2006.,5. bilateral knee replacements.,6. total abdominal hysterectomy and cholecystectomy.,family history:, multiple family members have diabetes mellitus.,social history:, the patient is retired on disability due to her knee replacements. she does not smoke, drink or use any illicit drugs.,medications:, percocet 5/325 mg 4-6 hours p.r.n., neurontin 100 mg per day, insulin, protonix 40 mg per day, toprol-xl 50 mg q.d., norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, lasix 20 mg b.i.d., and zocor 1 mg q.d.,allergies: , no known drug allergies.,physical examination: , blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. pain scale 5/10. please see the written note for details. general exam is benign other than mild obesity. on neuro examination, mental status is normal. cranial nerves are significant for full visual fields and pupils are equal and reactive. however, extraocular movements are very limited. she has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. face is symmetric. sensation is intact. tongue and uvula are in midline. palate is elevated symmetrically. shoulder shrug is strong. the patient's muscle exam shows normal bulk and tone throughout. she has no weakness of the left upper extremity. in the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. there is no drift or orbit. reflexes are absent throughout. sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. there is no dysmetria. gait is somewhat limited possibly by her vision and possibly also by her balance problems.,pertinent data:, as reviewed previously.,discussion: , this is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like guillain-barre syndrome, likely the miller-fisher variant. the patient has shown some improvement with ivig and continues to show some gradual improvement. i discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,i told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. she is scheduled to see an ophthalmologist. i think it is reasonable for close followup of her visual symptoms progress. however, i certainly would not take any corrective measures at this point as i suspect her vision will improve gradually.,i discussed with the patient that with respect to her back pain certainly the neurontin is relatively at low dose and this could be increased further. i wanted her to start taking the neurontin 300 mg per day and then 300 mg b.i.d. after one week. she will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,she was apparently given some baclofen by her internist and i think this is not unreasonable. i definitely hope to get her off the percocet in the future.,impression:,1. guillain-barre miller-fisher variant.,2. hypertension.,3. diabetes mellitus.,4. stroke.,recommendations:,1. the patient is to start taking aspirin 162 mg per day.,2. followup with ophthalmology.,3. increase neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4. followup by phone in three to four weeks.,5. followup in this clinic in approximately two months' time.,6. call for any questions or problems.

reason for consultation: , atrial fibrillation management.,history of present illness: ,the patient is a very pleasant 62-year-old african american female with a history of hypertension, hypercholesterolemia, and cva, referred by dr. x for evaluation and management of atrial fibrillation. the patient states that on monday during routine holt exam, it was detected by dr. x that her heart was irregular on exam. ekg obtained after that revealed atrial fibrillation, and subsequently the patient was started on coumadin as well as having toprol and referred for evaluation. the patient states that for the last 3 years, she has had episodes of her heart racing. it may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake. denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain. they subsequently resolve on their own and do not limit her in anyway. however, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe. she said she can walk no more than 25 feet without becoming tired. she states that she has to rest then her symptoms will go away, but she has been limited from that standpoint. denies peripheral edema, pnd, orthopnea, abdominal pain, swelling, recent fever or chills. she actually today has no complaints, and states that she has been compliant with her medications and has started taking her coumadin as directed.,past medical history:,1. hypertension.,2. myocardial infarction in 2003.,3. left heart catheterization at university hospital.,4. hypercholesterolemia.,5. arthritis.,6. cva in 2002 and in 2003 with right eye blindness.,past surgical history:,1. left total knee replacement in 2002.,2. left lower quadrant abscess drainage in 12/07,family medical history: , significant for lung and brain cancer. there is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,social history: , she is retired as a cook in a school cafeteria, where she worked for 34 years. she retired 7 years ago because of low back pain. she used to smoke 2-1/2 packs per day for 32 years, but quit in 1995. denies alcohol, and denies iv or illicit drug use.,allergies: , no known drug allergies.,medications:,1. coumadin 5 mg a day.,2. toprol-xl 50 mg a day.,3. aspirin 81 mg a day.,4. hydrochlorothiazide 25 mg a day.,5. plendil 10 mg daily.,6. lipitor 40 mg daily.,review of systems: ,as above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,physical examination:,vital signs: blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg. general: a well-developed, well-nourished, middle-aged african american female in no acute distress. neck: supple. no jvd. no carotid bruits. cardiovascular: irregularly irregular rate and rhythm. normal s1 and s2. no murmurs, gallops or rubs. lungs: clear to auscultation bilaterally. abdomen: bowel sounds positive, soft, nontender, and nondistended. no masses. extremities: no clubbing, cyanosis or edema. pulses 2+ bilaterally.,laboratory data: , ekg today revealed atrial fibrillation with nonspecific lateral t-wave abnormalities and a rate of 94.,impression: ,the patient is a very pleasant 62-year-old african american female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,recommendations:,1. her rate is suboptimally controlled, we will increase her toprol-xl to 75 mg per day.,2. we will obtain a transthoracic echocardiogram to evaluate her lv function as well as her valvular function.,3. we will check a thyroid function panel.,4. we will continue coumadin as directed and to follow up with dr. x for inr management.,5. given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on coumadin indefinitely.,6. depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization. we will await results of transthoracic echocardiogram.,7. we will arrange for the patient to wear a holter monitor to monitor the rate controlled on a 24-hour period. she will then return to the electrophysiology clinic in 1 month for followup visit with dr. y.,the patient was seen, discussed, and examined with dr. y in electrophysiology.

city, state,dear dr. y:,i had the pleasure of seeing abc today back in neurology clinic where he has been followed previously by dr. z. his last visit was in june 2006, and he carries a diagnosis of benign rolandic epilepsy. to review, his birth was unremarkable. he is a second child born to a g3, p1 to 2 female. he has had normal development, and is a bright child in 7th grade. he began having seizures, however, at 9 years of age. it is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep. he also had smaller spells with more focal convulsion and facial twitching. his eegs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere). most recent eeg in may 2006 shows the same abnormalities.,abc initially was placed on tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to trileptal. he has done very well taking 300 mg twice a day without any further seizures. his last event was the day of his last eeg when he was sleep deprived and was off medication. that was a convulsion lasting 5 minutes. he has done well otherwise. parents deny that he has any problems with concentration. he has not had any behavior issues. he is an active child and participates in sports and some motocross activities. he has one older sibling and he lives with his parents. father manages turkey farm with foster farms. mother is an 8th grade teacher.,family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known. there is no other relevant family history.,review of systems is positive for right heel swelling and tenderness to palpation. this is perhaps due to sports injury. he has not sprained his ankle and does not have any specific acute injury around the time that this was noted. he does also have some discomfort in the knees and ankles in the general sense with activities. he has no rashes or any numbness, weakness or loss of skills. he has no respiratory or cardiovascular complaints. he has no nausea, vomiting, diarrhea or abdominal complaints.,past medical history is otherwise unremarkable.,other workup includes ct scan and mri scan of the brain, which are both normal.,physical examination:,general: the patient is a well-nourished, well-hydrated male in no acute distress. vital signs: his weight today is 80.6 pounds. height is 58-1/4 inches. blood pressure 113/66. head circumference 36.3 cm. heent: atraumatic, normocephalic. oropharynx shows no lesions. neck: supple without adenopathy. chest: clear auscultation.,cardiovascular: regular rate and rhythm. no murmurs. abdomen: benign without organomegaly. extremities: no clubbing, cyanosis or edema. neurologic: the patient is alert and oriented. his cognitive skills appear normal for his age. his speech is fluent and goal-directed. he follows instructions well. his cranial nerves reveal his pupils equal, round, and reactive to light. extraocular movements are intact. visual fields are full. disks are sharp bilaterally. face moves symmetrically with normal sensation. palate elevates midline. tongue protrudes midline. hearing is intact bilaterally. motor exam reveals normal strength and tone. sensation intact to light touch and vibration. his gait is nonataxic with normal heel-toe and tandem. finger-to-nose, finger-nose-finger, rapid altering movements are normal. deep tendon reflexes are 2+ and symmetric.,impression: ,this is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic. most recent electroencephalogram still shows abnormalities, but it has not been done since may 2006. the plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal. at that time, he will be tapered off of medication. i anticipate at some point in the near future, within about a year or so, he will actually be taken off medication. for now, i will continue on trileptal 300 mg twice a day, which is a low starting dose for him. there is no indication that his dose needs to be increased. family understands the plan. we will try to obtain an electroencephalogram in the near future in modesto and followup is scheduled for 6 months. parents will contact us after the electroencephalogram is done so they can get the results.,thank you very much for allowing me to access abc for further management.

reason for visit:, followup status post l4-l5 laminectomy and bilateral foraminotomies, and l4-l5 posterior spinal fusion with instrumentation.,history of present illness:, ms. abc returns today for followup status post l4-l5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,preoperatively, her symptoms, those of left lower extremity are radicular pain.,she had not improved immediately postoperatively. she had a medial breech of a right l4 pedicle screw. we took her back to the operating room same night and reinserted the screw. postoperatively, her pain had improved.,i had last seen her on 06/28/07 at which time she was doing well. she had symptoms of what she thought was "restless leg syndrome" at that time. she has been put on requip for this.,she returned. i had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved. i had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative. she states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg. thus, i referred her for a lumbar spine radiograph and lumbar spine mri and she presents today for evaluation.,she states that overall, she is improved compared to preoperatively. she is ambulating better than she was preoperatively. the pain is not as severe as it was preoperatively. the right leg pain is improved. the left lower extremity pain is in a left l4 and l5 distribution radiating to the great toe and first web space on the left side.,she denies any significant low back pain. no right lower extremity symptoms.,no infectious symptoms whatsoever. no fever, chills, chest pain, shortness of breath. no drainage from the wound. no difficulties with the incision.,findings: ,on examination, ms. abc is a pleasant, well-developed, well-nourished female in no apparent distress. alert and oriented x 3. normocephalic, atraumatic. respirations are normal and nonlabored. afebrile to touch.,left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5. gastroc-soleus strength is 3 to 4 out of 5. this has all been changed compared to preoperatively. motor strength is otherwise 4 plus out of 5. light touch sensation decreased along the medial aspect of the left foot. straight leg raise test normal bilaterally.,the incision is well healed. there is no fluctuance or fullness with the incision whatsoever. no drainage.,radiographs obtained today demonstrate pedicle screw placement at l4 and l5 bilaterally without evidence of malposition or change in orientation of the screws.,lumbar spine mri performed on 07/03/07 is also reviewed.,it demonstrates evidence of adequate decompression at l4 and l5. there is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,assessment and plan: ,ms. abc is doing relatively well status post l4 and l5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07. the case is significant for merely misdirected right l4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,i am uncertain with regard to the etiology of the symptoms. however, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the mri demonstrates only a postoperative suprafascial fluid collection. i do not see any indication for another surgery at this time.,i would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,my recommendation at this time is that the patient is to continue with mobilization. i have reassured her that her spine appears stable at this time. she is happy with this.,i would like her to continue ambulating as much as possible. she can go ahead and continue with requip for the restless leg syndrome as her primary care physician has suggested. i have also her referred to mrs. khan at physical medicine and rehabilitation for continued aggressive management.,i will see her back in followup in 3 to 4 weeks to make sure that she continues to improve. she knows that if she has any difficulties, she may follow up with me sooner.

reason for examination:, abnormal ekg.,findings: , the patient was exercised according to standard bruce protocol for 9 minutes achieving maximal heart rate of 146 resulting in 85% of age-predicted maximal heart rate. peak blood pressure was 132/60. the patient did not experience any chest discomfort during stress or recovery. the test was terminated due to leg fatigue and achieving target heart rate.,electrocardiogram during stress and recovery did not reveal an additional 1 mm of st depression compared to the baseline electrocardiogram. technetium was injected at 5 minutes into stress.,impression:,1. good exercise tolerance.,2. adequate heart rate and blood pressure response.,3. this maximal treadmill test did not evoke significant and diagnostic clinical or electrocardiographic evidence for significant occlusive coronary artery disease.,

preoperative diagnoses: , open, displaced, infected left atrophic mandibular fracture; failed dental implant.,postoperative diagnoses: , open, displaced, infected left atrophic mandibular fracture; failed dental implant.,procedure performed: , open reduction and internal fixation (orif) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,anesthesia: , general nasotracheal.,estimated blood loss: , 125 ml.,fluids given: , 1 l of crystalloids.,specimen: , soft tissue from the fracture site sent for histologic diagnosis.,cultures: , also sent for gram stain, aerobic and anaerobic, culture and sensitivity.,indications for the procedure: , the patient is a 79-year-old male, who fell in his hometown, following an episode of syncope. he sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture. he was admitted to hospital in harleton, texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass. his mandible fracture was not noted initially. the patient also has a history of prostate cancer and a renal cell carcinoma. the patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending. the patient later saw a local oral surgeon. he diagnosed his mandible fracture and advised him to seek treatment in houston. he presented to my office for evaluation on january 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago. the patient had significant discomfort and could eat foods and drink fluids with difficulty. due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,procedure in detail: , the patient was taken to the operating room, and placed in a supine position. following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion. the patient was then prepped and draped in a manner consistent with sterile procedures. a marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible. a 1 ml of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue. a combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible. electrocautery as well as 4.0 silk ties were used for hemostasis. a 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site. the fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound. cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis. manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole synthes reconstruction plate was then used to stand on the fracture site. since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site. when the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically. all the screws were also locking screws. following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline. the incision was closed in multiple layers with 4.0 vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin. a sterile dressing was then placed over the incision. the patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs. estimated blood loss is 125 ml.

history and clinical data: ,the patient is an 88-year-old gentleman followed by dr. x, his primary care physician, dr. y for the indication of cll and dr. z for his cardiovascular issues. he presents to the care center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,he reports no clear-cut chest discomfort or difficulty with angina. he has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of cva, tia, nor peripheral vascular claudication.,review of systems:, general review of system is significant for difficulty with intermittent constipation, which has been problematic recently. he reports no fever, shaking chills, nothing supportive of gi or gu blood loss, no productive or nonproductive cough.,past medical history:, remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, copd, single vessel coronary disease, esophageal reflux, cll, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,social history: , remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,medications at home:, include, lortab 7.5 mg up to three times daily for chronic arthritic discomfort, miacalcin nasal spray once daily, omeprazole 20 mg daily, diovan 320 mg daily, combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to tekturna 150 mg daily, zoloft 25 mg daily.,allergies: ,he has known history of allergy to clonidine, medifast does fatigue.,diagnostic and laboratory data: , chest x-ray upon presentation to the ellis emergency room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,a 12-lead ekg, sinus rhythm at a rate of 68 per minute, right bundle-branch block type ivcv with moderate nonspecific st changes. low voltage in the limb leads.,wbc 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000. low serum sodium at 132, potassium 4, bun 28, creatinine 1.2, random glucose 179. low total protein 5.7. magnesium level 2.3, troponin 0.404 with the b-natriuretic peptide of 8200.,physical examination: ,he is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular. jvd difficult to assess. normal carotids with obvious bruits. conjunctivae pink. oropharynx clear. mild kyphosis. diffusely depressed breath sounds halfway up both posterior lung fields. no active wheezing. cardiac exam: regular, soft, 1-2/6 early systolic ejection murmur best heard at the base. abdomen: soft, nontender, protuberant, benign. extremities: 2+ bilateral pitting edema to the level of the knees. neuro exam: appears alert, oriented x3. appropriate manner and affect, exceedingly hard of hearing.,overall impression:, an 88-year-old white male with the following major medical issues:,1. presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2. hypertension with suboptimal controlled currently.,3. diabetes.,4. prostate ca, status post radium seed implant.,5. copd, on metered-dose inhaler.,6. cll followed by dr. y.,7. single-vessel coronary disease, no recent anginal quality chest pain, no changes in ecg suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8. hearing loss, anxiety.,9. significant degenerative joint disease.,plan:,1. admit to a4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2. strict i&o, foley catheter has already been placed.,3. daily bmp.,4. two-dimensional echocardiogram to assess left ventricular systolic function. serum iron determination to exclude the possibility of a subclinical ischemic cardiac event. further recommendations will be forthcoming pending his clinical course and hospital.

chief complaint:, left leg pain.,history of present illness:, the patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage iiic papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on saturday. the patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. a doppler ultrasound of her leg that was performed today noted a dvt. she is currently on course one, day 14 of 21 of taxol and carboplatin. she is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. she denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. she has a positive appetite and ambulates without difficulty.,past medical history:,1. gastroesophageal reflux disease.,2. mitral valve prolapse.,3. stage iiic papillary serous adenocarcinoma of the ovaries.,past surgical history:,1. a d and c.,2. bone fragment removed from her right arm.,3. ovarian cancer staging.,obstetrical history:, spontaneous miscarriage at 3 months approximately 30 years ago.,gynecological history: ,the patient started menses at age 12; she states that they were regular and occurred every month. she finished menopause at age 58. she denies any history of stds or abnormal pap smears. her last mammogram was in april 2005 and was within normal limits.,family history:,1. a sister with breast carcinoma who was diagnosed in her 50s.,2. a father with gastric carcinoma diagnosed in his 70s.,3. the patient denies any history of ovarian, uterine, or colon cancer in her family.,social history:, no tobacco, alcohol, or drug abuse.,medications:,1. prilosec.,2. tramadol p.r.n.,allergies:, no known drug allergies.,physical examination:,vital signs: temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, o2 saturation 99% on room air.,general: alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,heent: normocephalic and atraumatic. the oropharynx is clear. the pupils are equal, round, and reactive to light.,neck: good range of motion, nontender, no thyromegaly.,chest: clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,cardiovascular: regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,abdomen: positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,extremities: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. her left groin is slightly tender to palpation.,lymphatics: no axillary, groin, clavicular, or mandibular nodes palpated.,laboratory data:, white blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. sodium 142, potassium 3.3, chloride 103, co2 26, bun 15, creatinine 0.9, glucose 152, calcium 8.7. pt 13.1, ptt 28, inr 0.97.,assessment and plan:, miss bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage iiic papillary serous adenocarcinoma of the ovary. she is postop day 21 of an exploratory laparotomy with ovarian cancer staging. she is currently with a left leg dvt.,1. the patient is doing well and is currently without any complaints. we will start lovenox 1 mg per kg subcu daily and coumadin 5 mg p.o. daily. the patient will receive inr in the morning; the goal was obtain an inr between 2.5 and 3.0 before the lovenox is instilled. the patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. aranesp 200 mcg subcu was given today. the patient's absolute neutrophil count is 14,520.

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

chief complaint:, headache.,hpi: , this is a 24-year-old man who was seen here originally on the 13th with a headache and found to have a mass on ct scan. he was discharged home with a follow up to neurosurgery on the 14th. apparently, an mri the next day showed that the mass was an aneurysm and he is currently scheduled for an angiogram in preparation for surgery. he has had headaches since the 13th and complains now of some worsening of his pain. he denies photophobia, fever, vomiting, and weakness of the arms or legs.,pmh: , as above.,meds:, vicodin.,allergies:, none.,physical exam: ,bp 180/110 pulse 65 rr 18 temp 97.5.,mr. p is awake and alert, in no apparent distress.,heent: pupils equal, round, reactive to light, oropharynx moist, sclera clear. ,neck: supple, no meningismus.,lungs: clear.,heart: regular rate and rhythm, no murmur, gallop, or rub. ,abdomen: benign.,neuro: awake and alert, motor strength normal, no numbness, normal gait, dtrs normal. cranial nerves normal. ,course in the ed: ,patient had a repeat head ct to look for an intracranial bleed that shows an unchanged mass, no blood, and no hydrocephalus. i recommended an lp but he prefers not to have this done. he received morphine for pain and his headache improved. i've recommended admission but he has chosen to go home and come back in the morning for his scheduled angiogram. he left the ed against my advice. ,impression: , headache, improved. intracranial aneurysm.,plan: , the patient will return tomorrow am for his angiogram.

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

reason for consultation: , thyroid mass diagnosed as papillary carcinoma.,history of present illness: ,the patient is a 16-year-old young lady, who was referred from the pediatric endocrinology department by dr. x for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy. the patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004. an ultrasound examination had reportedly been done in the past and the mass is being observed. when it began to enlarge recently, she was referred to the pediatric endocrinology department and had an evaluation there. the patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma. the patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction. she has no weight changes consistent with either hyper or hypothyroidism. there is no family history of thyroid cancer in her family. she has no notable discomfort with this lesion. there have been no skin changes. historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,past medical history:, essentially unremarkable. the patient has never been hospitalized in the past for any major illnesses. she has had no prior surgical procedures.,immunizations: , current and up to date.,allergies: , she has no known drug allergies.,current medications: ,currently taking no routine medications. she describes her pain level currently as zero.,family history: , there is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter. this was done in tijuana. his mom is from central portion of mexico. there is no family history of multiple endocrine neoplasia syndromes.,social history: ,the patient is a junior at hoover high school. she lives with her mom in fresno.,review of systems: , a careful 12-system review was completely normal except for the problems related to the thyroid mass.,physical examination:,general: the patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress. she was alert and oriented x3 and had an appropriate affect.,heent: the head and neck examination is most significant. there is mild amount of facial acne. the patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,neck: there is a slightly visible midline bulge in the region of the thyroid isthmus. a firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid. this mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that i can determine. there are some shotty adenopathy in the area. no supraclavicular nodes were noted.,chest: excursions are symmetric with good air entry.,lungs: clear.,cardiovascular: normal. there is no tachycardia or murmur noted.,abdomen: benign.,extremities: extremities are anatomically correct with full range of motion.,genitourinary: external genitourinary exam was deferred at this time and can be performed later during anesthesia. this is same as too for her rectal examination.,skin: there is no acute rash, purpura, or petechiae.,neurologic: normal and no focal deficits. her voice is strong and clear. there is no evidence of dysphonia or vocal cord malfunction.,diagnostic studies: , i reviewed laboratory data from the diagnostics lab, which included a mild abnormality in the ast at 11, which is slightly lower than the normal range. t4 and tsh levels were recorded as normal. free thyroxine was normal, and the serum pregnancy test was negative. there was no level of thyroglobulin recorded on this. a urinalysis and comprehensive metabolic panel was unremarkable. a chest x-ray was obtained, which i personally reviewed. there is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,impression/plan: , the patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary. the pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease. i spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease. during this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy. we talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation. we also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well. i answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them. i also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit. this will have some impact on the postoperative adjunctive therapy. the radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case. i did discuss with them the possibility of having to take large doses of calcium and vitamin d in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity. all of the family's questions have been answered. this is a very anxious and anxiety provoking time in the family. i have made every effort to get the patient under schedule within the next 48 hours to have this operation done. we are tentatively planning on proceeding this upcoming friday afternoon with total thyroidectomy.

intensity-modulated radiation therapy simulation,the patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures. the target volume is adjacent to significant radiosensitive structures.,initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit. the patient is appropriately immobilized using a customized immobilization device. preliminary simulation films are obtained and approved by me. the patient is marked and transferred to the ct scanner. sequential images are obtained and transferred electronically to the treatment planning software. extensive analysis then occurs. the target volume, including margins for uncertainty, patient movement and occult tumor extension are selected. in addition organs at risk are outlined. appropriate doses are selected, both for the target, as well as constraints for organs at risk. inverse treatment planning is performed by the physics staff under my supervision. these are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.

subjective: , the patient is a 55-year-old african-american male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an mri scan, which demonstrated right contrast-enhancing temporal mass. given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma. ,objective: , the patient is alert and oriented times three, gcs of 15. cranial nerves ii to xii are grossly intact. motor exam demonstrates 5/5 strength in all four extremities. sensation is intact to light touch, pain, temperature, and proprioception. cerebellar exam is intact. gait is normal and tandem on heels and toes. speech is appropriate. judgment is intact. pupils are equal and reactive to light.,assessment and plan: , the patient is a 55-year-old african-american male with a new diagnosis of rim-enhancing right temporal mass. given the characteristics of the mri scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme. we have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing. given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma. the patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor. he agrees that he will be n.p.o. after mid night on wednesday night. he is sent for preoperative assessment with the anesthesiology tomorrow morning. he has undergone vocational rehab assessment.

preoperative diagnosis: , left distal ureteral stone.,postoperative diagnosis: , left distal ureteral stone.,procedure performed: , cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,anesthesia:, lma.,ebl: , minimal.,fluids: , crystalloid. the patient was given antibiotics, 1 g of ancef and the patient was on oral antibiotics at home.,brief history: , the patient is a 61-year-old female with history of recurrent uroseptic stones. the patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed. options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc. risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed. the patient understood and wanted to proceed with the procedure.,details of the procedure: , the patient was brought to the or. anesthesia was applied. the patient was placed in dorsal lithotomy position. the patient was prepped and draped in usual sterile fashion. a 0.035 glidewire was placed in the left system. using graspers, left-sided stent was removed. a semirigid ureteroscopy was done. a stone was visualized in the mid to upper ureter. using laser, the stone was broken into 5 to 6 small pieces. using basket extraction, all the pieces were removed. ureteroscopy all the way up to the upj was done, which was negative. there were no further stones. using pyelograms, the rest of the system appeared normal. the entire ureter on the left side was open and patent. there were no further stones. due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours. over the 0.035 glidewire, a 26 double-j stent was placed. there was a nice curl in the kidney and one in the bladder. the patient tolerated the procedure well. please note that the string was kept in place and the patient was to remove the stent the next day. the patient's family was instructed how to do so. the patient had antibiotics and pain medications at home. the patient was brought to recovery room in a stable condition.

final diagnoses:, delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,procedure: , included primary low transverse cesarean section.,summary: , this 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks. the patient underwent a 2-day induction. on the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress. during the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration. secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication. there was a slightly enlarged blood loss at approximately 1200 ml, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees fahrenheit temperature right at delivery. it was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay. the patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees fahrenheit. the maternal tachycardia resolved within a day. the patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns. the patient did receive 2 units of packed red cells on sunday when attended to by my partner secondary to a hematocrit of 20%. it should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively. therefore, there was anemia but not an unexplained anemia.,physical examination on discharge: , includes the stable vital signs, afebrile state. an alert and oriented patient who is desirous at discharge. full range of motion, all extremities; fully ambulatory. pulse is regular and strong. lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus. the incision is beautiful and soft and nontender. there is scant lochia and there is minimal edema.,laboratory studies: , include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,followup: , for the patient includes pelvic rest, regular diet. follow up with me in 1 to 2 weeks. motrin 800 mg p.o. q.8h. p.r.n. cramps, tylenol no. 3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.

history of present illness: , this is a 12-year-old male, who was admitted to the emergency department, who fell off his bicycle, not wearing a helmet, a few hours ago. there was loss of consciousness. the patient complains of neck pain.,chronic/inactive conditions:, none.,personal/family/social history/illnesses:, none.,previous injuries: , minor.,medications: , none.,previous operations: , none.,allergies: ,none known.,family history: , negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,social history: , the patient is single. he is a student. he does not smoke, drink alcohol or consume drugs.,review of systems,constitutional: the patient denies weight loss/gain, fever, chills.,enmt: the patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,cv: the patient denies chest pain, sob supine, palpitations, edema, varicose veins, leg pains.,respiratory: the patient denies sob, wheezing, sputum production, bloody sputum, cough.,gi: the patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,gu: the patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,ms: the patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,neuro: the patient had a loss of consciousness during the accident. he does not recall the details of the accident. otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,psych: negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,integumentary: negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,physical examination,constitutional: blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air. the patient shows moderate obesity.,neck: the neck is symmetric, the trachea is in the midline, and there are no masses. no crepitus is palpated. the thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,respirations: normal respiratory effort. there is no intercostal retraction or action by the accessory muscles. normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,cardiovascular: the pmi is palpable at the 5ics in the mcl. no thrills on palpation. s1 and s2 are easily audible. no audible s3, s4, murmur, click or rub. abdominal aorta is not palpable. no audible abdominal bruits. femoral pulses are 3+ bilaterally, without audible bruits. extremities show no edema or varicosities.,gastrointestinal: no palpable tenderness or masses. liver and spleen are percussed but not palpable under the costal margins. no evidence for umbilical or groin herniae.,lymphatic: no nodes over 3 mm in the neck, axillae or groins.,musculoskeletal: normal gait and station. the patient is on a stretcher. symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,skin: there is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees. no induration or subcutaneous nodules to palpation.,neurologic: normal sensation by touch. the patient moves all four extremities.,psychiatric: oriented to time, place, and person. appropriate mood and affect.,laboratory data: reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an mri of the head, which is normal.,diagnoses,1. concussion.,2. facial abrasion.,3. scalp laceration.,4. knee abrasions.,plans/recommendations:, admitted for observation.

history of present illness: ,this is a 23-year-old married man who had an onset of aplastic anemia in december, underwent a bone marrow transplant in the end of march, has developed very severe graft-versus-host reaction. psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,the patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in abcd that was about two years ago. gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. he would drink up to half of a fifth of rum on a daily basis when available.,the patient is currently on lexapro 10 mg in the morning and diazepam 10 mg at bedtime. he complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. he would have a limited support system here in colorado. he married in january and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in july. i would recommend some couples counseling as a part of their treatment here.,the patient was fairly drowsy during the interview and full past and developmental history was not obtained. the patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in xyz area because he did not like school.,physical examination: ,general: , this is a cooperative man, speech is soft and difficult to understand. there is no thought disorder and no hallucination. he denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,vital signs: , temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,psychiatry:, there is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. activities of daily living (adls) appear intact. on formal testing, he is oriented to place. he can give a reasonable recitation of his medical history. he is oriented to the year, knows it is the 15th, but gave the month as june instead of may. he can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. he can do serial three subtractions accurately, can name objects appropriately.,laboratory data:, sodium of 135, bun of 24, and glucose 119. ggt of 355, alt of 97, ldh of 703, and alk phos of 144. fk506 is 28.8, which is elevated tacrolimus level. hematocrit 29% and white count is 7000.,diagnoses: ,axis i:, depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,axis ii: , personality disorder, not otherwise specified (nos).,axis iii: , history of polysubstance abuse, in remission.,recommendations: ,1. this patient appears to retain the ability to make decisions on his own behalf. i think he is mentally competent. unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. if the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. the patient does complain of depressed mood, also of anxiety. we did discuss medications. he appeared somewhat sedated at the time of my interview. i would recommend that we try seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. i will have dr. x followup with him.,please feel free to contact me at digital pager if additional information is needed.,my overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.

chief complaint:, nausea and abdominal pain after eating.,gall bladder history:, the patient is a 36 year old white female. patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. the patient's symptoms have been present for 3 months. complaints are relieved with lying on right side and antacids. prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without cbd obstruction. laboratory studies that are elevated include total bilirubin and elevated wbc.,past medical history:, no significant past medical problems.,past surgical history:, diagnostic laparoscopic exam for pelvic pain/adhesions.,allergies:, no known drug allergies.,current medications:, no current medications.,occupational /social history:, marital status: married. patient states smoking history of 1 pack per day. patient quit smoking 1 year ago. admits to no history of using alcohol. states use of no illicit drugs.,family medical history:, there is no significant, contributory family medical history.,ob gyn history:, lmp: 5/15/1999. gravida: 1. para: 1. date of last pap smear: 1/15/1998.,review of systems:,cardiovascular: denies angina, mi history, dysrhythmias, palpitations, murmur, pedal edema, pnd, orthopnea, tia's, stroke, amaurosis fugax.,pulmonary: denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, tb exposure or treatment.,neurological: patient admits to symptoms of seizures and ataxia.,skin: denies scaling, rashes, blisters, photosensitivity.,physical examination:,appearance: healthy appearing. moderately overweight.,heent: normocephalic. eom's intact. perrla. oral pharynx without lesions.,neck: neck mobile. trachea is midline.,lymphatic: no apparent cervical, supraclavicular, axillary or inguinal adenopathy.,breast: normal appearing breasts bilaterally, nipples everted. no nipple discharge, skin changes.,chest: normal breath sounds heard bilaterally without rales or rhonchi. no pleural rubs. no scars.,cardiovascular: regular heart rate and rhythm without murmur or gallop.,abdominal: bowel sounds are high pitched.,extremities: lower extremities are normal in color, touch and temperature. no ischemic changes are noted. range of motion is normal.,skin: normal color, temperature, turgor and elasticity; no significant skin lesions.,impression diagnosis: , gall bladder disease. abdominal pain.,discussion:, laparoscopic cholecystectomy handout was given to the patient, reviewed with them and questions answered. the patient has given both verbal and written consent for the procedure.,plan:, we will proceed with laparoscopic cholecystectomy with intraoperative cholangiogram.,medications prescribed:,

preoperative diagnoses:,1. acute pain.,2. fever postoperatively.,postoperative diagnosis:,1. acute pain.,2. fever postoperatively.,3. hemostatic uterine perforation.,4. no bowel or vascular trauma.,procedure performed:,1. diagnostic laparoscopy.,2. rigid sigmoidoscopy by dr. x.,anesthesia: , general endotracheal.,complications: , none.,estimated blood loss: , scant.,specimen:, none.,indications: ,this is a 17-year-old african-american female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03. the patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2. the patient denied any nausea, vomiting or diarrhea. she does complain of some frequent urination. her vaginal bleeding is minimal.,findings: , on bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated. on laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus. there is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac. the bilateral tubes and ovaries appeared normal. there is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap. there is no evidence of injury to the bowel or pelvic sidewall. the liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,procedure: , after consent was obtained, the patient was taken to the operating room where general anesthetic was administered. the patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion. a sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum. the uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed. gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made. veress needle was placed through this incision and the gas turned on. when good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate. a 11 mm trocar was then placed through this incision. the camera was placed with the above findings noted. a 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline. a blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs. the serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline. at this point, dr. x was consulted. he performed a rigid sigmoidoscopy, please see his dictation for further details. there does not appear to be any evidence of colonic injury. the saline in the pelvis was then suctioned out using nezhat-dorsey. all instruments were removed. the 5 mm trocar was removed under direct visualization with excellent hemostasis noted. the camera was removed and the abdomen was allowed to desufflate. the 11 mm trocar introducer was replaced and the trocar removed. the skin was then closed with #4-0 undyed vicryl in a subcuticular fashion. approximately 10 cc of 0.25% marcaine was injected into the incision sites for postoperative pain relief. steri-strips were then placed across the incision. the uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted. the patient tolerated the procedure well. sponge, lap, and needle counts were correct at the end of the procedure. the patient was taken to the recovery room in satisfactory condition.,she will be followed immediately postoperatively within the hospital and started on iv antibiotics.

procedure: , right ventricular pacemaker lead placement and lead revision.,indications:, sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,equipment: , a new lead is a medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1. the original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,estimated blood loss: , 5 ml.,procedure description: ,conscious sedation with versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine. the patient received a venogram documenting patency of the subclavian vein. skin incision with blunt and sharp dissection. electrocautery for hemostasis. the pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads. the leads were sequentially checked. through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava. ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture. pocket was irrigated with antibiotic solution. the pocket was packed with bacitracin-soaked gauze. this was removed during the case and then irrigated once again. the generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 monocryl.,conclusion: , successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous vitatron pulse generator model # 12345.

admission diagnosis: , bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,secondary diagnosis:, chronic pain syndrome.,principal procedure: , l5 gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation. this was performed by dr. x on 01/08/08.,brief history of hospital course: , the patient is a man with a history of longstanding back, buttock, and bilateral leg pain. he was evaluated and found to have bilateral pars defects at l5-s1 with spondylolysis and instability. he was admitted and underwent an uncomplicated surgical procedure as noted above. in the postoperative period, he was up and ambulatory. he was taking p.o. fluids and diet well. he was afebrile. his wounds were healing well. subsequently, the patient was discharged home.,discharge medications: , discharge medications included his usual preoperative pain medication as well as other medications.,followup: ,at this time, the patient will follow up with me in the office in six weeks' time. the patient understands discharge plans and is in agreement with the discharge plan. he will follow up as noted

preoperative diagnosis:, benign prostatic hyperplasia.,postoperative diagnosis:, benign prostatic hyperplasia.,operation performed: , transurethral electrosurgical resection of the prostate.,anesthesia: , general.,complications:, none.,indications for the surgery:, this is a 77-year-old man with severe benign prostatic hyperplasia. he has had problem with urinary retention and bladder stones in the past. he will need to have transurethral resection of prostate to alleviate the above-mentioned problems. potential complications include, but are not limited to:,1. infection.,2. bleeding.,3. incontinence.,4. impotence.,5. formation of urethral strictures.,procedure in detail: , the patient was identified, after which he was taken into the operating room. general lma anesthesia was then administered. the patient was given prophylactic antibiotic in the preoperative holding area. the patient was then positioned, prepped and draped. cystoscopy was then performed by using a #26-french continuous flow resectoscopic sheath and a visual obturator. the prostatic urethra appeared to be moderately hypertrophied due to the lateral lobes and a large median lobe. the anterior urethra was normal without strictures or lesions. the bladder was severely trabeculated with multiple bladder diverticula. there is a very bladder diverticula located in the right posterior bladder wall just proximal to the trigone. using the ***** resection apparatus and a right angle resection loop, the prostate was resected initially at the area of the median lobe. once the median lobe has completely resected, the left lateral lobe and then the right lateral lobes were taken down. once an adequate channel had been achieved, the prostatic specimen was retrieved from the bladder by using an ellik evacuator. a 3-mm bar electrode was then introduced into the prostate to achieve perfect hemostasis. the sheath was then removed under direct vision and a #24-french foley catheter was then inserted atraumatically with pinkish irrigation fluid obtained. the patient tolerated the operation well.

title of operation: ,1. secondary scleral suture fixated posterior chamber intraocular lens implant with penetrating keratoplasty.,2. a concurrent vitrectomy and endolaser was performed by the vitreoretinal team.,indication for surgery: ,the patient is a 62-year-old white male who underwent cataract surgery in 09/06. this was complicated by posterior capsule rupture. an intraocular lens implant was not attempted. he developed corneal edema and a preretinal hemorrhage. he is aware of the risks, benefits, and alternatives of the surgery and now wishes to proceed with secondary scleral suture fixated posterior chamber intraocular lens implant in the left eye, vitrectomy, endolaser, and penetrating keratoplasty.,preop diagnosis: ,1. preretinal hemorrhage.,2. diabetic retinopathy.,3. aphakia.,4. corneal edema.,postop diagnosis: ,1. preretinal hemorrhage.,2. diabetic retinopathy.,3. aphakia.,4. corneal edema.,anesthesia: , general.,specimen: ,1. donor corneal swab sent to microbiology.,2. donor corneal scar rim sent to eye pathology.,3. the patient's cornea sent to eye pathology.,pros dev implant: ,abc laboratories 16.0 diopter posterior chamber intraocular lens, serial number 123456.,narrative: , informed consent was obtained, and all questions were answered. the patient was brought to the preoperative holding area, where the operative left eye was marked. he was brought to the operating room and placed in the supine position. ekg leads were placed. general anesthesia was induced. the left ocular surface and periorbital skin were disinfected and draped in the standard fashion for eye surgery after a shield and tape were placed over the unoperated right eye. a lid speculum was placed. the posterior segment infusion was placed by the vitreoretinal service. peritomy was performed at the 3 and 9 o'clock limbal positions. a large flieringa ring was then sutured to the conjunctival surface using 8-0 silk sutures tied in an interrupted fashion. the cornea was then measured and was found to accommodate a 7.5-mm trephine. the center of the cornea was marked. the keratoprosthesis was identified.,a 7.5-mm trephine blade was then used to incise the anterior corneal surface. this was done after a paracentesis was placed at the 1 o'clock position and viscoelastic was used to dissect peripheral anterior synechiae. once the synechiae were freed, the above-mentioned trephination of the anterior cornea was performed. corneoscleral scissors were then used to excise completely the central cornea. the keratoprosthesis was placed in position and was sutured with six interrupted 8-0 silk sutures. this was done without difficulty. at this point, the case was turned over to the vitreoretinal team, which will dictate under a separate note. at the conclusion of the vitreoretinal procedure, the patient was brought under the care of the cornea service. the 9-0 prolene sutures double armed were then placed on each lens haptic loop. the keratoprosthesis was removed. prior to this removal, scleral flaps were made, partial thickness at the 3 o'clock and 9 o'clock positions underneath the peritomies. wet-field cautery also was performed to achieve hemostasis. the leading hepatic sutures were then passed through the bed of the scleral flap. these were drawn out of the eye and then used to draw the trailing hepatic into the posterior segment of the eye followed by the optic. the trailing hepatic was then placed into the posterior segment of the eye as well. the trailing haptic sutures were then placed through the opposite scleral flap bed and were withdrawn. these were tied securely into position with the iol nicely centered. at this point, the donor cornea punched at 8.25 mm was then brought into the field. this was secured with four cardinal sutures. the corneal button was then sutured in place using a 16-bite 10-0 nylon running suture. the knot was secured and buried after adequate tension was adjusted. the corneal graft was watertight. attention was then turned back to the iol sutures, which were locked into position. the ends were trimmed. the flaps were secured with single 10-0 nylon sutures to the apex, and the knots were buried. at this point, the case was then turned back over to the vitreoretinal service for further completion of the retinal procedure. the patient tolerated the corneal portions of the surgery well and was turned over to the retina service in good condition, having tolerated the procedure well. no complications were noted. the attending surgeon, dr. x, performed the entire procedure. no complications of the procedure were noted. the intraocular lens was selected from preoperative calculations. no qualified resident was available to assist.

preoperative diagnoses,1. basal cell nevus syndrome.,2. cystic lesion, left posterior mandible.,3. corrected dentition.,4. impacted teeth 1 and 16.,5. maxillary transverse hyperplasia.,postoperative diagnoses,1. basal cell nevus syndrome.,2. cystic lesion, left posterior mandible.,3. corrected dentition.,4. impacted teeth 1 and 16.,5. maxillary transverse hyperplasia.,procedure,1. removal of cystic lesion, left posterior mandible.,2. removal of teeth numbers 4, 13, 20, and 29.,3. removal of teeth numbers 1 and 16.,4. modified le fort i osteotomy.,indications for the procedure:, the patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome. currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified le fort osteotomy.,procedure in detail:, the patient was brought into the operating room, placed on the operating table in supine position. following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures. the oral cavity was suctioned, was drained of fluid and a throat pack was placed. general anesthesia nursing service was notified and which was removed at the end of the procedure. lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 ml. a bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth. subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt. following use of cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle. secondly, tooth number 4 was removed. tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side. surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9. this resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion. these wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure. attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar. the surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle. this wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin. closed primarily with a 3-0 vicryl suture in running fashion for a watertight closure. teeth number 20 and 29 where removed and 3-0 chromic suture placed. this concluded the procedure. all cottonoids and other sponges, throat pack were removed. no complications were encountered. the aforementioned cystic lesion was sent with specimen no drains were placed. the blood loss from this procedure was approximately 100 ml.,the patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.

introduction: , the opinions expressed in this report are those of the physician. the opinions do not reflect the opinions of evergreen medical panel, inc. the claimant was informed that this examination was at the request of the washington state department of labor and industries (l&i). the claimant was also informed that a written report would be sent to l&i, as requested in the assignment letter from the claims manager. the claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by l&i, and was not intended as a general medical examination.,chief complaints: , this 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on november 20, 2008.,history of industrial injury:, this patient was injured on november 20, 2008. he works at the purdy correctional facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. the patient said he primarily landed on the left side. after the accident he states that he was generally stun and someone at the institute advised him to be evaluated. he went to a gig harbor urgent care facility and they sent him on to tacoma general hospital. at the tacoma general, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a ct scan. the patient describes that he had a brain ct and a dark spot was found. it was recommended that he have a followup mri and this was done locally and showed a recurrent acoustic neuroma. before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in october 2005. the patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. overall his spine complaints have improved substantially.,after the fall, he also saw at prompt care in the general bremerton area, xyz, an osteopathic physician and she examined him and released him full duty and also got an orthopedic consult from xyz. she ordered an mri of his neck. cervically this showed that he had a mild disc bulge at c4-c5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,since 2002 the patient has been seeing the chiropractor, xyz for general aches and pain and this has included some treatments on his back and neck.,current symptoms: ,the patient describes his current pain as being intermittent.,past medical history:,illnesses: the patient had a diagnosis in 2005 of an acoustic neuroma. it was benign, but treated neurosurgically. in february 2004 and again in august 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,operations: he has a history of an old mastoidectomy. he has a past history of removal of an acoustic neuroma in 2005 as noted.,medications: the patient takes occasional tylenol and occasional aleve.,substance use:,tobacco: he does not smoke cigarettes.,alcohol: he drinks about five beers a week.,family history:, his father died of mesothelioma and his mother died of lou gehrig's disease.,socioeconomic history:,marital status and dependents: the patient has been married three times; longest marriage is of two years duration. he has two children. these dependents are ages 15 and twins and are his wife's dependents.,education: the patient has bachelor's degree.,military history: he served six years in the army and received an honorable discharge.,work history: he has worked at purdy correctional institute in gig harbor for 19 years.,chart review: , review of the chart indicates a date of injury of november 20, 2008. he was seen at tacoma general hospital with a diagnosis of head contusion and cervical strain. he had a ct of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended. he has a history of an old mastoidectomy. he was then seen on november 24, 2008 by xyz at prompt care on november 24, 2008. there is no clearcut history that he had lost consciousness. he has a past history of removal of an acoustic neuroma in 2005 as noted. a diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal ct and previous resection of an acoustic neuroma. some symptoms of loss of balance and confusion were noted. she recommended additional testing and neurologic evaluation.,the notes from the treating chiropractor begin on november 24, 2008. adjustments are given to the cervical, thoracic, and lumbar spine.,he was seen back by xyz on december 9, 2008 and he had been released to full duties. it was recognized the new mri suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard. there were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma. he continued to have chiropractic adjustments. he was seen back at prompt care on january 8, 2009. dr. x indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,a followup note by his chiropractor on january 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,on april 13, 2009, he was seen again at prompt care for his cervical and thoracic strain. he was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate. therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,on april 17, 2009, he was seen by dr. x, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,a repeat consult was carried out on april 29, 2009 by xyz. he felt that this was hyperextension cervical injury. it might take a period of time to recover. he mentioned that the patient might have a slight ulnar neuropathy. he felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,this concludes the chart review.,physical examination: , the patient is 6 feet in height, weighs 255 pounds.,orthopedic examination: he can walk with a normal gait, but he has, as indicated, a positive romberg test and he himself has noticed that if he closes his eyes he loses his balance. overall the patient is a seemingly good historian. there is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly. these are secondary to drawing for the skull markers. there is a scar behind the patient's left ear from the original treatment of the acoustic neuroma. this was well healed. the patient can perform a toe-heel gait without difficulty. one visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering. the patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had. the patient has a full range of motion in both of his shoulders. the patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees. there is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest. he extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction. there is slight tenderness on palpating over the right cervical musculature. there is no evidence of any cervical or lumbar muscle spasms. reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis. knee jerks are 2+ and ankle jerks are 1+. tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally. the patient's grip tested with a jamar dynamometer increases from 70 to 80 pounds bilaterally. sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left. testing of muscle strength in the upper and lower extremities is normal. the patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally. the forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally. the thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm. pressure on the vertex of the head does not bother the patient. axial loading is negative. as already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,diagnostic studies: , x-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the l4-5 disc space. the hip joints are normal. views of his thoracic spine are normal. cervical x-rays are in the file. these are of intermittent quality, but the views do show a very slight degree of anterior spurring at the c4-5 with possible slight narrowing of the disc. there is a view of the right shoulder that is unremarkable.,conclusions:, the accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,diagnoses: , diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan. the patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,discussion: , he is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of november 20, 2008. further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine. he is category i relative to the cervical spine under 296-20-240 and category i to the lumbosacral spine under wac 296-20-270. his industrial case should be closed and there is, as indicated, no basis for any disability award.

title of operation: , central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck. left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side. right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,indication for surgery: , the patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer. the patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease. fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer. risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed. the risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others. the patient understood all these issues and did wish to proceed.,procedure detail: ,after identifying the patient, the patient was placed supine on the operating room table. the patient was intubated with a number 7 nerve integrity monitor system endotracheal tube. the eyes were protected with tegaderm. the patient was rotated to 180 degrees towards the operating surgeon. the foley catheter was placed into the bladder with good return of urine. attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately. a previous apron incision was incorporated and advanced over onto the right side to the mastoid tip. the incision then was planned around the old scar to be excised. a 1% lidocaine with 1 to 100,000 epinephrine was injected. a shoulder roll was applied. the incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly. attention was then turned to performing the level 1 dissection on the left. subsequently the marginal mandibular nerve was identified over the facial notch of the mandible. the facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve. level 1a lymph nodes of the submental region were dissected off the mylohyoid and digastric. the submandibular gland was appreciated and retracted laterally. the mylohyoid muscle appreciated. the lingual nerve was appreciated and the submandibular ganglion was ligated. the hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis. the marginal mandibular nerve stimulated at the completion of this portion of the procedure. attention was then turned to incising the fascia along the clavicle on the left side. dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified. the brachial plexus and phrenic nerve were identified. the internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels. attention was then turned to the central neck. the strap muscles were appreciated in the midline. there was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature. a careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed. attention was then turned to identify the carotid artery and the internal jugular vein on the left side. this was traced inferiorly, internal jugular vein to the brachiocephalic vein. palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass. subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis. attention was then turned to the right neck dissection. a posterior flap on the right was raised to the anterior border of the trapezius. the accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly. attention was then turned to identifying the submandibular gland. a digastric tunnel was performed back to the sternocleidomastoid muscle. the fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated. the omohyoid muscle was retracted inferiorly. penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle. subsequently the internal jugular vein was identified. the external jugular vein ligated about 1 cm above the clavicle. palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex. dissection along the floor of the neck then was performed to allow for mobilization. the transverse cervical artery and vein were individually ligated to allow full mobilization of this mass. tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated. the tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly. the cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base. the hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein. the wound was copiously irrigated. valsalva maneuver was given. no bleeding points identified. the wound was then prepared for closure. two number 10 jps were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon. the wound was closed with interrupted 3-0 vicryl for platysma, subsequently a 4-0 running biosyn for the skin, and indermil. the patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.

identification: , the patient is a 15-year-old female.,chief complaint: , right ankle pain.,history of present illness:, the patient was running and twisted her right ankle. there were no other injuries. she complains of right ankle pain on the lateral aspect. she is brought in by her mother. her primary care physician is dr. brown.,review of systems:, otherwise negative except as stated above.,past medical history:, none.,past surgical history: , none.,medications:, none.,social history: , mother appears loving and caring. there is no evidence of abuse.,allergies:, no known drug allergies.,physical examination: , general: the patient is alert and oriented x4 in mild distress without diaphoresis. she is nonlethargic and nontoxic. vitals: within normal limits. the right ankle shows no significant swelling. there is no ecchymosis. there is no significant tenderness to palpation. the ankle has good range of motion. the foot is nontender. vascular: +2/2 dorsalis pedis pulse. all compartments are soft. capillary refill less than 2 seconds.,diagnostic test:, the patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,medical decision making: , due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home. she is able to walk on it without significant pain, thus i recommend rest for 1 week and follow up with the doctor if she has persistent pain. she may need to see a specialist, but at this time this is a very mild ankle injury. there is no significant physical finding, and i foresee no complications. i will give her 1 week off of pe.,morbidity/mortality:, i expect no acute complications. a full medical screening exam was done and no emergency medical condition exists upon discharge.,complexity:, moderate. the differential includes fracture, contusion, abrasion, laceration, and sprain.,assessment:, right ankle sprain.,plan:, discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist. she is advised to return immediately p.r.n. severe pain, worsening, not better, etc.

preoperative diagnoses:,1. abnormal uterine bleeding.,2. enlarged fibroid uterus.,3. hypermenorrhea.,4. intermenstrual spotting.,5. thickened endometrium per ultrasound of a 2 cm lining.,postoperative diagnoses:,1. abnormal uterine bleeding.,2. enlarged fibroid uterus.,3. hypermenorrhea.,4. intermenstrual spotting.,5. thickened endometrium per ultrasound of a 2 cm lining.,6. grade 1+ rectocele.,procedure performed: ,d&c and hysteroscopy.,complications: , none.,history: , the patient is a 48-year-old para 2, vaginal delivery. she has heavy periods lasting 7 to 14 days with spotting in between her periods. the patient's uterus is 12.2 x 6.2 x 5.3 cm. her endometrial thickness is 2 cm. her adnexa is within normal limits. the patient and i had a long discussion. consent was reviewed in layman's terms. the patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery. questions were answered. the patient was taken back to the operative suite. the patient underwent pelvic examination and then carefully placed in dorsal lithotomy position. the patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities. the patient's history is that she is at risk for development of condyloma. the patient's husband was found to have a laryngeal papillomatosis. she has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation. her uterus appears to be mobile by 12-week size. there is a good descend. there appears to be no adnexal abnormalities. uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis. the patient's cervix was dilated without difficulty utilizing circon acmi hysteroscope with a 12-degree lens. the patient underwent hysteroscopy. the outflow valve was opened at all times. the inflow valve was opened just to achieve appropriate distension. the patient did have no evidence of trauma of the cervix. no trendelenburg as we were in room #9. the patient also had the bag held two fingerbreadths above the level of the heart. the patient was seen. there is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature. the patient also has one in the fundal area. the thickened tissue was removed via sharp curettage. therefore, we reinserted the hysteroscope. it appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed. the patient's procedure was ended with specimen being obtained and sent to department of pathology. we will follow her up in the office.

preoperative diagnoses:,1. nonfunctioning inflatable penile prosthesis.,2. peyronie's disease.,postoperative diagnoses:,1. nonfunctioning inflatable penile prosthesis.,2. peyronie's disease.,procedure performed: , ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis ams700.,anesthesia:, general lma.,specimen: , old triple component inflatable penile prosthesis.,procedure: ,this is a 64-year-old male with prior history of peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,operative procedure: , after informed consent, the patient was brought to the operative suite and placed in the supine position. general endotracheal intubation was performed by the anesthesia department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra. the bladder was subsequently drained with a red robinson catheter. at that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space. care was maintained to avoid all bleeding as possible secondary to the fact that we could not use bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture. at that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies. attention was taken then to the tubing, going up to the reservoir in the right lower quadrant. this was dissected out bluntly and sharply with metzenbaum scissors and monopolar used for hemostasis. at this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis. as we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery. at that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum. this was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 prolene stay ties, staying lateral and anterior on the corporal body. the corporal body was opened up and the cylinder was removed from the right side without difficulty. however, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures. this was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body. the left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted. after removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen. both corporal bodies were then dilated with the pratt dilators. these were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces. at this point, using the farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally. he had an 18 cm with rear tips in place, which were removed. we decided to go ahead to and use another 18 cm inflatable penile prosthesis. confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest. we felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm. at this point, we went ahead and placed the right cylinder using the farlow device and the keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty. attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders. this then forced us to down size to the 1 cm rear tips, which slipping very easily with the farlow device through the glans penis. there was no crossover and no violation of the tunica albuginea. the rear tips were then placed without difficulty and our corporotomies were closed with #2-0 pds in a running fashion. ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants. at that point, the wound was copiously irrigated and the device was inflated multiple times. there was a very good fit and we had a very good result. at that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution. this was held in place with a babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump. please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty. the entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated. after completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result. at that point, after irrigation again of the space, the area was simply dry and hemostatic. the soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers. the soft tissue and the skin was then reapproximated with staples. please also note that prior to the skin closure, a jackson-pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours. this was also sutured in place with nylon. sterile dressing was applied. light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally. coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine. no foley catheter was used or placed.,the patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition. he will be admitted overnight to the service of dr. mcdevitt. cardiology will be asked to consult with dr. stomel for a pacer placement and he will be placed on the telemetry floor and kept on iv antibiotics.

preoperative diagnoses:,1. cellulitis with associated abscess, right foot.,2. foreign body, right foot.,postoperative diagnoses:,1. cellulitis with associated abscess, right foot.,2. foreign body, right foot.,procedure performed:,1. irrigation debridement.,2. removal of foreign body of right foot.,anesthesia:, spinal with sedation.,complications:, none.,estimated blood loss: , minimal.,gross findings: , include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,history of present illness: , the patient is a 61-year-old caucasian male with a history of uncontrolled diabetes mellitus. the patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. he notes some itching as well as increasing pain and redness in the right foot and presented to abcd general hospital emergency room. he was evaluated by the emergency room staff as well as the medical team and the department of orthopedics. it was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. after a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,procedure: , after all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained. the operative extremity was then confirmed with the patient, operative surgeon, the department of anesthesia and nursing staff. the patient was then transferred to preoperative area to operative suite #5 and placed on the operating table in supine position. all bony prominences were well padded at this time. the department of anesthesia was administered spinal anesthetic to the patient. once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion. upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from. at this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads. upon incising this, there was a foul smelling purulent fluid, which flowed from this region. aerobic and anaerobic cultures were taken as well as gram stain. the area was explored and it ________ to the dorsum of the foot. there was no obvious joint involvement. after all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound. the wound was again inspected with no more gross purulent or necrotic appearing tissue. the wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and kerlix covered by an ace bandage. at this time, the department of anesthesia reversed the sedation. the patient was transferred back to the hospital gurney to postanesthesia care unit. the patient tolerated the procedure well and there were no complications.,disposition: ,the patient will be followed on a daily basis for possible repeat irrigation debridement.

problem list:,1. hiv stable.,2. hepatitis c chronic.,3. history of depression, stable off meds.,4. hypertension, moderately controlled.,chief complaint: , the patient comes for a routine followup appointment.,history of presenting illness: , this is a 34-year-old african american female who comes today for routine followup. she has no acute complaints. she reports that she has a muscle sprain on her upper back from lifting. the patient is a housekeeper by profession. it does not impede her work in anyway. she just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. no other associated complaints. no neurological deficits or other specific problems. the patient denies any symptoms associated with opportunistic infection.,past medical history:,1. significant for hiv.,2. hepatitis.,3. depression.,4. hypertension.,current medications:,1. she is on trizivir 1 tablet p.o. b.i.d.,2. ibuprofen over-the-counter p.r.n.,medication compliance: , the patient is 100% compliant with her meds. she reports she does not miss any doses.,allergies: , she has no known drug allergies.,drug intolerance: ,there is no known drug intolerance in the past.,nutritional status: , the patient eats regular diet and eats 3 meals a day.,review of systems: , noncontributory except as mentioned in the hpi.,laboratory data: , most recent labs from 11/07.,radiological data:, she has had no recent radiological procedures.,immunizations: , up-to-date.,sexual history: , she has had no recent stds and she is not currently sexually active. ppd status was negative in the past. ppd will be placed again today.,treatment adherence counseling was performed by both nursing staff and myself. again, the patient is a 100% compliant with her meds. last dental exam was in 11/07, where she had 2 teeth extracted. last pap smear was 1 year ago was negative. the patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. she has no family history of breast cancer.,mental health and substance abuse: , the patient has a history of depression. no history of substance abuse.,advanced directive: , unknown.,physical examination:,general: this is a thinly built female, not in acute distress. vital signs: temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds. head and neck: reveals bilaterally reactive pupils. supple neck. no thrush. no adenopathy. heart: heart sounds s1 and s2 regular. no murmur. lungs: clear bilaterally to auscultation. abdomen: soft and nontender with good bowel sounds. neurologic: she is alert and oriented x3 with no focal neurological deficit. extremities: peripheral pulses are felt bilaterally. she has no pitting pedal edema, clubbing or cyanosis. gu: examination of external genitalia is unremarkable. there are no lesions.,laboratory data: , from 11/07 shows hemoglobin and hematocrit of 16 and 46. creatinine of 0.6. lfts within normal limits. viral load of less than 48 and cd4 count of 918.,assessment:,1. human immunodeficiency virus, stable on trizivir.,2. hepatitis c with stable transaminases.,3. history of depression, stable off meds.

reason for neurological consultation: , cervical spondylosis and kyphotic deformity. the patient was seen in conjunction with medical resident dr. x. i personally obtained the history, performed examination, and generated the impression and plan.,history of present illness: ,the patient is a 45-year-old african-american female whose symptoms first started some one and a half years ago with pain in the left shoulder and some neck pain. this has subsequently resolved. she started vigorous workouts in november 2005. in march of this year, she suddenly could not feel her right foot on the bathroom floor and subsequently went to her primary care physician. by her report, she had a nerve conduction study and a diagnosis of radiculopathy was made. she had an mri of lumbosacral spine, which was within normal limits. she then developed a tingling sensation in the right middle toe. symptoms progressed to sensory symptoms of her knees, elbows, and left middle toe. she then started getting sensory sensations in the left hand and arm. she states that she feels a little bit wobbly at the knees and that she is slightly dragging her left leg. symptoms have been mildly progressive. she is unaware of any trigger other than the vigorous workouts as mentioned above. she has no associated bowel or bladder symptoms. no particular position relieves her symptoms.,workup has included two mris of the c-spine, which were personally reviewed and are discussed below. she saw you for consultation and the possibility of surgical decompression was raised. at this time, she is somewhat reluctant to go through any surgical procedure.,past medical history:,1. ocular migraines.,2. myomectomy.,3. infertility.,4. hyperglycemia.,5. asthma.,6. hypercholesterolemia.,medications: , lipitor, pulmicort, allegra, xopenex, patanol, duac topical gel, loprox cream, and rhinocort.,allergies: , penicillin and aspirin.,family history, social history, and review of systems are discussed above as well as documented in the new patient information sheet. of note, she does not drink or smoke. she is married with two adopted children. she is a paralegal specialist. she used to exercise vigorously, but of late has been advised to stop exercising and is currently only walking.,review of systems: , she does complain of mild blurred vision, but these have occurred before and seem associated with headaches.,physical examination: , on examination, blood pressure 138/82, pulse 90, respiratory rate 14, and weight 176.5 pounds. pain scale is 0. a full general and neurological examination was personally performed and is documented on the chart. of note, she has a normal general examination. neurological examination reveals normal cognition and cranial nerve examination including normal jaw jerk. she has mild postural tremor in both arms. she has mild decreased sensation in the right palm and mild decreased light touch in the right palm and decreased vibration sense in both distal lower extremities. motor examination reveals no weakness to individual muscle testing, but on gait she does have a very subtle left hemiparesis. she has hyperreflexia in her lower extremities, worse on the left. babinski's are downgoing.,pertinent data: ,mri of the brain from 05/02/06 and mri of the c-spine from 05/02/06 and 07/25/06 were personally reviewed. mri of the brain is broadly within normal limits. mri of the c-spine reveals large central disc herniation at c6-c7 with evidence of mild cord compression and abnormal signal in the cord suggesting cord edema. there is also a fairly large disc at c3-c4 with cord deformity and partial effacement of the subarachnoid space. i do not appreciate any cord edema at this level.,impression and plan: ,the patient is a 45-year-old female with cervical spondylosis with a large c6-c7 herniated disc with mild cord compression and signal change at that level. she has a small disc at c3-c4 with less severe and only subtle cord compression. history and examination are consistent with signs of a myelopathy.,results were discussed with the patient and her mother. i am concerned about progressive symptoms. although she only has subtle symptoms now, we made her aware that with progression of this process, she may have paralysis. if she is involved in any type of trauma to the neck such as motor vehicle accident, she could have an acute paralysis. i strongly recommended to her and her mother that she followup with you as soon as possible for surgical evaluation. i agree with the previous physicians who have told her not to exercise as i am sure that her vigorous workouts and weight training since november 2005 have contributed to this problem. i have recommended that she wear a hard collar while driving. the results of my consultation were discussed with you telephonically.

preoperative diagnosis:, acute acalculous cholecystitis.,postoperative diagnosis: , acute acalculous cholecystitis.,procedure:, placement of cholecystostomy tube under ultrasound guidance.,anesthesia: , xylocaine 1% with epinephrine.,indications: , patient is a pleasant 75-year-old gentleman who is about one week status post an acute mi who also has acute cholecystitis. because it is not safe to take him to the operating room for general anesthetic, i recommended he undergo the above-named procedure. procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,technique: , patient was identified, then taken to the radiology suite, where the area of interest was identified using ultrasound and prepped with betadine solution, draped in sterile fashion. after infiltration with 1% xylocaine and after multiple attempts, the gallbladder was finally cannulated by dr. kindred using the cook 18-french needle. the guidewire was then placed and via seldinger technique, a 10-french pigtail catheter was placed within the gallbladder, secured using the cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.

neurological examination: , at present the patient is awake, alert and fully oriented. there is no evidence of cognitive or language dysfunction. cranial nerves: visual fields are full. funduscopic examination is normal. extraocular movements full. pupils equal, round, react to light. there is no evidence of nystagmus noted. fifth nerve function is normal. there is no facial asymmetry noted. lower cranial nerves are normal. ,manual motor testing reveals good tone and bulk throughout. there is no evidence of pronator drift or decreased fine finger movements. muscle strength is 5/5 throughout. deep tendon reflexes are 2+ throughout with downgoing toes. sensory examination is intact to all modalities including stereognosis, graphesthesia.,testing of station and gait:, the patient is able to walk toe-heel and tandem walk. finger-to-nose and heel-to-shin moves are normal. romberg sign negative. i appreciate no carotid bruits or cardiac murmurs.,noncontrast ct scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.

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.

preoperative diagnosis: , ruptured globe with uveal prolapse ox.,postoperative diagnosis:, ruptured globe with uveal prolapse ox.,procedure: ,repair of ruptured globe with repositing of uveal tissue ox.,anesthesia: ,general,specimens:, none.,complications:, none.,indications: , this is a xx-year-old (wo)man with a ruptured globe of the xxx eye.,procedure: , the risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. informed consent was obtained. the patient received iv antibiotics including ancef and levaeuin prior to surgery. the patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. a wire lid speculum was carefully placed to provide exposure. a two-armed 7 mm scleral laceration was seen in the supranasal quadrant. the laceration involved the sclera and the limbus in this area. there was a small amount of iris tissue prolapsed in the wound. the westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. a cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. the anterior chamber remained formed and the iris tissue easily resumed its normal position. the pupil appeared round. an 8-0 nylon suture was used to close the scleral portion of the laceration. three sutures were placed using the 8-0 nylon suture. then 9-0 nylon suture was used to close the limbal portion of the wound. after the wound appeared closed, a superblade was used to create a paracentesis at approximately 2 o'clock. bss was injected through the paracentesis to fill the anterior chamber. the wound was checked and found to be watertight. no leaks were observed. an 8-0 vicryl suture was used to reposition the conjunctiva and close the wound. three 8-0 vicryl sutures were placed in the conjunctiva. all scleral sutures were completely covered. the anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. subconjunctival injections of ancef and dexamethasone were given at the end of the case as well as tobradex ointment. the lid speculum was carefully removed. the drapes were carefully removed. sterile saline was used to clean around the xxx eye as well as the rest of the face. the area was carefully dried and an eye patch and shield were taped over the xxx eye. the patient was awakened from general anesthesia without difficulty. (s)he was taken to the recovery area in good condition. there were no complications.

preoperative diagnoses:,1. chronic nasal obstruction secondary to deviated nasal septum.,2. inferior turbinate hypertrophy.,postoperative diagnoses:,1. chronic nasal obstruction secondary to deviated nasal septum.,2. inferior turbinate hypertrophy.,procedure performed:,1. nasal septal reconstruction.,2. bilateral submucous resection of the inferior turbinates.,3. bilateral outfracture of the inferior turbinates.,anesthesia:, general endotracheal tube.,blood loss: , minimal less than 25 cc.,indications: , the patient is a 51-year-old female with a history of chronic nasal obstruction. on physical examination, she was derived to have a severely deviated septum with an s-shape deformity as well as turbinate hypertrophy present along the inferior turbinates contributing to the obstruction.,procedure: ,after all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained. the patient was brought to the operating suite where she was placed in the supine position and general endotracheal intubation was delivered by the department of anesthesia. the patient was rotated 90 degrees away. nasal pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavities. these were then removed and the nasal septum as well as the turbinates were localized with the mixture of 1% lidocaine with 1:100000 epinephrine solution. the nasal pledgets were then reinserted as the patient was prepped in the usual fashion. the nasal pledgets were again removed and the turbinates as well as an infraorbital nerve block was performed with 0.25% marcaine solution. the nasal vestibules were then cleansed with a phisohex solution. a #15 blade scalpel was then used to make an incision along the length of the caudal septum. the mucoperichondrial junction was then identified with the aid of cotton-tipped applicator as well as the stitch scissor. once the plane was identified, the mucosal flap on the left side of the septum was elevated with the aid of a cottle. at this point it should be mentioned that the patient's septum was significantly deviated with a large s-shape deformity obstructing both the right and left nasal cavity with the convex portion present in the left nasal cavity. again, the cottle elevator was used to raise the mucosal flap down to the level of the septal spur. at this point, the septal knife was used to make a crossover incision through the cartilage just anterior to the septal spur. again, the mucosal flap was elevated in the right nasal septum. now knight scissors were used to remove the ascending portion of the nasal cartilage, which was then removed with a takahashi forceps. a cottle elevator was used to further elevate the mucosal flap off the septal spur on the left side. removal of the spur was performed with the aid of the septal knife as well as a 3 mm straight chisel. once all ascending cartilage has been removed, inspection of the nasal cavity revealed patent passages with the exception of inferior turbinates that were very hypertrophied and was felt to be contributing to the patient's symptoms. therefore, the turbinates were again localized and a #15 blade scalpel was used to make a vertical incision dissected down to the chondral bone. the xps microdebrider with the inferior turbinate blade was then inserted through the incision and a submucous resection was performed by passing the microdebrider along the length of the bone. once the submucosal tissue had been resected, an outfracture procedure was performed so as to fully open the nasal passages. inspection revealed very patent and nonobstructive nasal passages. now the caudal incision was reapproximated with #4-0 chromic suture. finally, a #4-0 fast absorbing plain gut suture was used to approximate the mucosal surface of the septum in a running whipstitch fashion. finally, merocel packing was placed and the patient was retuned to the department of anesthesia for awakening and taken to the recovery room without incident.

reason:, right lower quadrant pain.,history of present illness: ,the patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank. she states that is particularly bad when up and walking around, goes away when she is lying down. she has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm. she states that she feels a bit like she did when she had her gallbladder removed nine years ago. additionally, i should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles. she has no abnormal vaginal discharge, and she is sexually active.,allergies:, no known drug allergies.,medications,1. hydrochlorothiazide 25 mg p.o. daily.,2. lisinopril 10 mg p.o. daily.,3. albuterol p.r.n.,past medical history: ,hypertension and seasonal asthma.,past surgical history: , left bilateral breast biopsy for benign disease. cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,family history: , mother is alive and well. father with coronary artery disease. she has siblings who have increased cholesterol.,social history: ,the patient does not smoke. she quit 25 years ago. she drinks one beer a day. she works as a medical transcriptionist.,review of systems: , positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,physical examination,general: reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,vital signs: her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,heent: normocephalic and atraumatic. sclerae are without icterus. conjunctivae are not injected.,neck: neck is supple. carotids 2+. trachea is midline. carotids are without bruits.,lymph nodes: there is no cervical, supraclavicular, or occipital adenopathy.,lungs: clear to auscultation.,cardiac: regular rate and rhythm.,abdomen: soft. no hepatosplenomegaly. she has a positive rovsing sign and a positive obturator sign. she is tender in the right lower quadrant with mild rebound and no guarding.,extremities: reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses. she has only trace edema with varicosities around the bilateral ankles.,cns: without gross neurologic deficits.,integumentary: skin integrity is excellent.,diagnostics: , urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells. white blood cell count is 20,000 with 75 polys and 16 lymphs. h&h is 13.7 and 39.7. total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98. sodium 138, potassium 3.1, chloride 101, co2 26, calcium 9.5, glucose 103, bun 16, and creatinine 0.91. lipase is 19. cat scan is negative for acute appendicitis. in fact, it mentions that the appendix is not discretely identified. there are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,impression: , abdominal pain right lower quadrant, etiology is unclear.,plan:, plan is to admit the patient. recheck the white blood cell count in the morning. re-examine her and further plan is pending, the results of that evaluation.

preoperative diagnoses:,1. enlarging nevus of the left upper cheek.,2. enlarging nevus 0.5 x 1 cm, left lower cheek.,3. enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,title of procedures:,1. excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2. excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3. shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,anesthesia: ,local. i used a total of 5 ml of 1% lidocaine with 1:100,000 epinephrine.,estimated blood loss: , less than 10 ml.,complications:, none.,procedure: , the patient was evaluated preop and noted to be in stable condition. chart and informed consent were all reviewed preop. all risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient. risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed. each of these lesions appears to be benign nevi; however, they have been increasing in size. the lesions involving the left upper and lower cheek appear to be deep. these required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision. each of these lesions was marked. the skin was cleaned with a sterile alcohol swab. local anesthetic was infiltrated. sterile prep and drape were then performed.,began first excision of the left upper cheek skin lesion. this was excised with the 15-blade full thickness. once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,the lesion of the lower cheek was removed in a similar manner. again, it was excised with a 15 blade with two layer plastic closure. both these lesions appear to be fairly deep nevi.,the right nasal ala nevus was superficially shaved using the radiofrequency wave unit. each of these lesions was sent as separate specimens. the patient was discharged from my office in stable condition. he had minimal blood loss. the patient tolerated the procedure very well. postop care instructions were reviewed in detail. we have scheduled a recheck in one week and we will make further recommendations at that time.

exam: , dobutamine stress test.,indication: , chest pain.,type of test: , dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,interpretation: , resting heart rate of 66 and blood pressure of 88/45. ekg, normal sinus rhythm. post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate. blood pressure 120/42. ekg remained the same. no symptoms were noted.,impression:,1. nondiagnostic dobutamine stress test.,2. nuclear interpretation as below.,nuclear interpretation: , resting and stress images were obtained with 10.8, 30.2 mci of tetrofosmin injected intravenously by standard protocol. nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. gated and spect revealed normal wall motion and ejection fraction of 75%. end-diastolic volume was 57 and end-systolic volume of 12.,impression:,1. normal nuclear myocardial perfusion scan.,2. ejection fraction of 75% by gated spect.

bender-gestalt test: , not organic.,beck testing:,depression: 37,anxiety: 41,hopelessness: 10,suicide ideation: 18,summary:, the patient was cooperative and appeared to follow the test instructions. there is no evidence of organicity on the bender. he endorsed symptoms of depression and anxiety. he has moderately negative expectancies regarding his future and is expressing suicidal ideation. great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.

subjective:, this is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type i diabetes. the patient reports that she was hospitalized over the weekend for dka. she indicates that her blood sugar on friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. she gave herself, in smaller increments, a total of 70 extra units of her humalog. ten of those units were injectable; the others were in the forms of pump. her blood sugar was over 600 when she went to the hospital later that day. she is here at this consultation complaining of not feeling well still because she has a cold. she realizes that this is likely because her immune system was so minimized in the hospital.,objective:, current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. her basal rates have not been changed since her last visit with charla yassine and totaled 30.5 units per 24 hours. a diet history was obtained. i instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. a correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. the lilly guide for meal planning was provided and reviewed. additional carbohydrate counting book was provided.,assessment:, the patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. it is based on the 500 rule which suggests this ratio. we did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. we also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. she does seem to have a pattern of fixing blood sugars later in the day after they are elevated. we discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. with this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. joanne araiza joined our consultation briefly to discuss whether her pump was working appropriately. the patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,plan:, recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. this was a one-hour consultation. provided my name and number should additional needs arise.

preoperative diagnosis: , syncopal episodes with injury. see electrophysiology consultation.,postoperative diagnoses:,1. normal electrophysiologic studies.,2. no inducible arrhythmia.,3. procainamide infusion negative for brugada syndrome.,procedures:,1. comprehensive electrophysiology studies with attempted arrhythmia induction.,2. iv procainamide infusion for brugada syndrome.,description of procedure:, the patient gave informed consent for comprehensive electrophysiologic studies. she received small amounts of intravenous fentanyl and versed for conscious sedation. then 1% lidocaine local anesthesia was used. three catheters were placed via the right femoral vein; 5-french catheters to the right ventricular apex and right atrial appendage; and a 6-french catheter to the his bundle. later in the procedure, the rv apical catheter was moved to rv outflow tract.,electrophysiological findings:, conduction intervals in sinus rhythm were normal. sinus cycle length 768 ms, pa interval 24 ms, ah interval 150 ms, hv interval 46 ms. sinus node recovery times were also normal at 1114 ms. corrected sinus node recovery time was normal at 330 ms. one-to-one av conduction was present to cycle length 480 ms, ah interval 240 ms, hv interval 54 ms. av nodal effective refractory period was normal, 440 ms at drive cycle length 600 ms. ra-erp was 250 ms. with ventricular pacing, there was va disassociation present.,since there was no evidence for dual av nodal pathways, and poor retrograde conduction, isoproterenol infusion was not performed to look for svt.,programmed ventricular stimulation was performed at both right ventricular apex and right ventricular outflow tracts. drive cycle length 600, 500, and 400 ms was used with triple extrastimuli down to troubling intervals of 180 ms, or refractoriness. there was no inducible vt. longest run was 5 beats of polymorphic vt, which is a nonspecific finding. from the apex 400-600 with 2 extrastimuli were delivered, again with no inducible vt.,procainamide was then infused, 20 mg/kg over 10 minutes. there were no st segment changes. hv interval after iv procainamide remained normal at 50 ms.,assessment: , normal electrophysiologic studies. no evidence for sinus node dysfunction or atrioventricular block. no inducible supraventricular tachycardia or ventricular tachycardia, and no evidence for brugada syndrome.,plan: , the patient will follow up with dr. x. she recently had an ambulatory eeg. i will plan to see her again on a p.r.n. basis should she develop a recurrent syncopal episodes. reveal event monitor was considered, but not placed since she has only had one single episode.

indication for study: , elevated cardiac enzymes, fullness in chest, abnormal ekg, and risk factors.,medications:, femara, verapamil, dyazide, hyzaar, glyburide, and metformin.,baseline ekg: , sinus rhythm at 84 beats per minute, poor anteroseptal r-wave progression, mild lateral st abnormalities.,exercise results:,1. the patient exercised for 3 minutes stopping due to fatigue. no chest pain.,2. heart rate increased from 84 to 138 or 93% of maximum predicted heart rate. blood pressure rose from 150/88 to 210/100. there was a slight increase in her repolorization abnormalities in a non-specific pattern.,nuclear protocol: ,same day rest/stress protocol was utilized with 11 mci for the rest dose and 33 mci for the stress test.,nuclear results:,1. nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. the resting images showed decreased uptake in the anterior wall. however the apex is spared of this defect. there is no significant change between rest and stress images. the sum score is 0.,2. the gated spect shows moderate lvh with slightly low ef of 48%.,impression:,1. no evidence of exercise induced ischemia at a high myocardial workload. this essentially excludes obstructive cad as a cause of her elevated troponin.,2. mild hypertensive cardiomyopathy with an ef of 48%.,3. poor exercise capacity due to cardiovascular deconditioning.,4. suboptimally controlled blood pressure on today's exam.

exam:,mri spinal cord cervical without contrast,clinical:,right arm pain, numbness and tingling.,findings:,vertebral alignment and bone marrow signal characteristics are unremarkable. the c2-3 and c3-4 disk levels appear unremarkable.,at c4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. a discrete cord signal abnormality is not identified. there may also be some narrowing of the neuroforamina at this level.,at c5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. distinct neuroforaminal narrowing is not evident.,at c6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. distinct cord compression is not evident. there may be mild narrowing of the neuroforamina at his level.,a specific abnormality is not identified at the c7-t1 level.,impression:,disk/osteophyte at c4-5 through c6-7 with contact and may mildly indent the ventral cord contour at these levels. some possible neuroforaminal narrowing is also noted at levels as stated above.

admission diagnosis: , right tibial plateau fracture.,discharge diagnoses: , right tibial plateau fracture and also medial meniscus tear on the right side.,procedures performed:, open reduction and internal fixation (orif) of right schatzker iii tibial plateau fracture with partial medial meniscectomy.,consultations: , to rehab, dr. x and to internal medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,hospital course: , the patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right schatzker iii tibial plateau fracture and partial medial meniscectomy performed without incidence. the patient seemed to be recovering well. the patient spent the next several days on the floor, nonweightbearing with cpm machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. the patient was given nebulizer treatment and lasix increased the same to resolve the problem. the patient was comfortable, stabilized, breathing well. on day #12, was transferred to abcd.,discharge instructions: , the patient is to be transferred to abcd after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,diet:, regular.,activity and limitations: , nonweightbearing to the right lower extremity. the patient is to continue cpm machine while in bed along with antiembolic stockings. the patient will require nursing, physical therapy, occupational therapy, and social work consults.,discharge medications: , resume home medications, but increase lasix to 80 mg every morning, lovenox 30 mg subcu daily x2 weeks, vicodin 5/500 mg one to two every four to six hours p.r.n. pain, combivent nebulizer every four hours while awake for difficulty breathing, zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,followup: , follow up with dr. y in 7 to 10 days in office.,condition on discharge:, stable.

exam: , transesophageal echocardiogram and direct current cardioversion.,reason for exam: ,1. atrial fibrillation with rapid ventricular rate.,2. shortness of breath.,procedure: , after informed consent was obtained, the patient was then sedated using a total of 4 mg of versed and 50 mcg of fentanyl. following this, transesophageal probe was placed in the esophagus. transesophageal views of the heart were then obtained.,findings:,1. left ventricle is of normal size. overall lv systolic function is preserved. estimated ejection fraction is 60% to 65%. no wall motion abnormalities are noted.,2. left atrium is dilated.,3. left atrial appendage is free of clots.,4. right atrium is of normal size.,5. right ventricle is of normal size.,6. mitral valve shows evidence of mild mac.,7. aortic valve is sclerotic without significant restriction of leaflet motion.,8. tricuspid valve appears normal.,9. pulmonic valve appears normal.,10. pacer wires are noted in the right atrium and in the right ventricle.,11. doppler interrogation of moderate mitral regurgitation is present.,12. mild-to-moderate ai is seen.,13. no significant tr is noted.,14. no significant ti is noted.,15. no pericardial disease seen.,impression:,1. preserved left ventricular systolic function.,2. dilated left atrium.,3. moderate mitral regurgitation.,4. aortic valve sclerosis with mild-to-moderate aortic insufficiency.,5. left atrial appendage is free of clots.,following these, direct current cardioversion was performed. three biphasic shock waves of 150 and two of 200 joules were then applied to the patient's chest in anteroposterior direction without success in conversion to sinus rhythm. the patient remained in atrial fibrillation.,plan: , plan will be to continue medical therapy. we will consider using beta-blocker, calcium channel blockers for better ventricular rate control.

reason for visit:, mr. a is an 86-year-old man who returns for his first followup after shunt surgery.,history of present illness: ,i have followed mr. a since may 2008. he presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control. we established a diagnosis of adult hydrocephalus with the spinal catheter protocol in june of 2008 and ,mr. a underwent shunt surgery performed by dr. x on august 1st. a medtronic strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,mr. a comes today with his daughter, pam and together they give his history.,mr. a has had no hospitalizations or other illnesses since i last saw him. with respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery. his balance has improved though he still has some walking impairment. with respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,with respect to his cognition, both pam and the patient say that his thinking has improved. the other daughter, patty summarized it best according to two of them. she said, "i feel like i can have a normal conversation with him again." mr. a has had no headaches and no pain at the shunt site or at the abdomen.,medications: , plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., flomax 0.4 mg p.o. q.d., zocor 20 mg p.o. q.d., detrol la 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., imodium daily, omega-3, fish oil, and lasix.,major findings:, mr. a is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,vital signs: blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,the shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,mental status: tested for recent and remote memory, attention span, concentration, and fund of knowledge. he scored 26/30 on the mmse when tested with spelling and 25/30 when tested with calculations. of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. this was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,gait: tested using the tinetti assessment tool. he was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. this has slightly improved from his initial score of 15-17/28.,cranial nerves: pupils are equal. extraocular movements are intact. face symmetric. no dysarthria.,motor: normal for bulk and strength.,coordination: slow for finger-to-nose.,imaging: , ct scan was reviewed from 10/15/2008. it shows a frontal horn span at the level of foramen of munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. by my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. this was not noticed by the radiologist who stated no extraaxial fluid collections. there is also substantial small vessel ischemic change.,assessment: , mr. a has made some improvement since shunt surgery.,problems/diagnoses:,1. adult hydrocephalus (331.5).,2. gait impairment (781.2).,3. urinary incontinence and urgency (788.33).,4. cognitive impairment (290.0).,plan:, i had a long discussion with mr. a and his daughter. we are all pleased that he has started to make some improvement with his hydrocephalus because i believe i see a tiny fluid collection in the right parietal region, i would like to leave the setting at 2.0 for another three months before we consider changing the shunt. i do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the ct scan.,mr. a asked me about whether he will be able to drive again. unfortunately, i think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. i would certainly be happy to recommend such a test if i believe ,mr. a is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, i think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. i also think it is quite likely he will not regain sufficient speed of motion to pass such a test.

preoperative diagnoses:,1. chronic pelvic pain.,2. hypermenorrhea.,3. desire for future fertility.,4. failed conservative medical therapy.,postoperative diagnoses:,1. chronic pelvic pain.,2. hypermenorrhea.,3. desire for future fertility.,4. failed conservative medical therapy.,5. possible adenomyosis.,6. left hydrosalpinx.,7. suspicion for endometriosis.,procedures performed:,1. dilation and curettage (d&c).,2. laparoscopy.,3. harmonic scalpel ablation of lesion which is suspicious for endometriosis.,anesthesia: , general with endotracheal tube.,estimated blood loss: , less than 20 cc.,complications:, none.,indications: , this is a 35-year-old caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion. this patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living. symptoms have not improved with prescription of oral contraceptives.,the patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996. the cyst was not diagnosed as an endometrioma. the patient does desire future fertility; however, would like a definitive diagnosis. conservative medical therapy was offered i.e. lupron or repeat oral contraceptives, but declined.,findings:, bimanual exam reveals a small retroverted uterus which is easily mobile. there were no adnexal masses. the cervix was normal on palpation. a fibrotic band was noted at the internal os during dilation. on laparoscopic exam, the uterus was found to be small with mild spongy texture. on palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis. the left ovary was grossly normal. the left fallopian tube had a mild hydrosalpinx present. the left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis. the vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac. the liver appeared grossly normal. there were no obvious pelvic adhesions. the left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,procedure: ,the patient was seen in the preop suite. history was reviewed and all questions were answered. the patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube. she was placed in a dorsal lithotomy position in allen stirrups. she was prepped and draped in the normal sterile fashion. her bladder was drained with a red robinson catheter producing approximately 100 cc of clear yellow urine. a bimanual exam was performed by dr. x, dr. y, and dr. z with above findings noted. a sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum. there was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible. a #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen. an infraumbilical incision was made using skin scalpel. the veress needle was placed and co2 was insufflated. it was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the co2 was discontinued and veress needle was completely removed. a second attempt placement of the veress needle into the abdomen was successful and co2 was insufflated approximately 3 liters with minimal intraabdominal pressure. the #12 port was placed and the laparoscope was inserted. attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position. the cervix was serially dilated using hank dilators to allow for introduction of the sharp curette. a curettage was then performed and specimen of the endometrium was sent for pathologic evaluation. this procedure was performed under direct laparoscopic visualization. laparoscopic evaluation of the pelvis was performed and the above findings noted. a second abdominal incision was performed suprapubically using a skin scalpel and the veress needle was placed through the incision successfully under direct visualization. a #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization. the manipulator was then removed and the harmonic scalpel was placed through the #5 port. the harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament. the lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis. there was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment. the harmonic scalpel was removed from the abdomen as was the #5 port. the incision was internally found to be hemostatic. the laparoscope was then removed from the abdomen. the abdomen was desufflated. the introducer was then replaced into the #12 port and the #12 port was removed from the abdomen. the uterine manipulator was removed from the uterus and the cervix was found to be hemostatic. the weighted speculum was then removed. the patient taken out of dorsal lithotomy position. she was recovered from general anesthesia and taken to the postoperative suite for complete recovery. the patient's discharge instructions will include a followup in one to two weeks in dr. x's office for discussion of pathology. her family was notified of the findings. she will be instructed not to have intercourse or use tampons or douche for the next two weeks. the patient will be sent home with a prescription for darvocet for pain.

preoperative diagnosis:, dorsal ganglion, right wrist.,postoperative diagnosis:, dorsal ganglion, right wrist.,operations performed:, excision dorsal ganglion, right wrist.,anesthesia:, monitored anesthesia care with regional anesthesia applied by surgeon.,tourniquet time:, minutes.,description of procedure: , with the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner. the arm was exsanguinated and the tourniquet was elevated to 290 mm/hg. a transverse incision was made over the dorsal ganglion. using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field. the extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field. the ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto. care was taken to protect ligament integrity. reactive synovium was then removed using soft tissue rongeur technique. the wound was then infiltrated with 0.25% marcaine. the tendons were allowed to resume their normal anatomical position. the skin was closed with 3-0 prolene subcuticular stitch. sterile dressings were applied. the tourniquet was deflated. the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.

procedure:, laparoscopic cholecystectomy.,discharge diagnoses:,1. acute cholecystitis.,2. status post laparoscopic cholecystectomy.,3. end-stage renal disease on hemodialysis.,4. hyperlipidemia.,5. hypertension.,6. congestive heart failure.,7. skin lymphoma 5 years ago.,8. hypothyroidism.,hospital course: , this is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left av fistula done about 3 days ago by dr. x and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family. the patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85. ekg was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm. there is sludge in the gallbladder wall versus a stone in the gallbladder wall. thickening of the gallbladder wall with positive murphy sign. she has a history of cholecystitis. urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal. so, the patient admitted to the med/surg floor initially and the patient was started on iv fluid as well as low-dose iv antibiotic and 2-d echocardiogram and ekg also was ordered. the patient also had history of chf in the past and recently had some workup done. the patient does not remember initially. surgical consult also requested and blood culture and urine culture also ordered. the same day, the patient was seen by dr. y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by dr. z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy. the patient also seen by nephrologist and underwent dialysis. the patient's white count went down 6.1, afebrile. on postop day #1, the patient started eating and also walking. the patient also had chronic bronchitis. the patient was later on feeling fine, discussed with surgery. the patient was then able to discharge to home and follow with the surgeon in about 3-5 days. discharged home with synthroid 0.5 mg 1 tablet p.o. daily, plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, diovan 80 mg p.o. daily, renagel 2 tablets 800 mg p.o. twice a day, lasix 40 mg p.o. 2 tablets twice a day, lovastatin 20 mg p.o. daily, coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also phenergan 25 mg p.o. q.8 hours for nausea and vomiting, pepcid 20 mg p.o. daily, vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and levaquin 250 mg p.o. every other day for the next 5 days. the patient also had premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient. discharged home.

history of present illness:, ms. a is a 55-year-old female who presented to the bariatric surgery service for consideration of laparoscopic roux-en-y gastric bypass. the patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including weight watchers, nutrisystem, jenny craig, tops, cabbage diet, grape fruit diet, slim-fast, richard simmons, as well as over-the-counter measures without any long-term sustainable weight loss. at the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46. she has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,past medical history:, significant for hypertension, for which the patient takes norvasc and lopressor for. she also suffers from high cholesterol and is on lovastatin for this. she has depression, for which she takes citalopram. she also stated that she had a dvt in the past prior to her hysterectomy. she also suffers from thyroid disease in the past though this is unclear, the nature of this.,past surgical history: , significant for cholecystectomy in 2008 for gallstones. she also had a hysterectomy in 1994 secondary to hemorrhage. the patient denies any other abdominal surgeries.,medications: , norvasc 10 mg p.o. daily, lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin d, premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin d 50,000 units q. weekly.,allergies: , the patient denies allergies to medications and to latex.,social history: , the patient is a homemaker. she is married, with 2 children aged 22 and 28. she is a lifelong nonsmoker and nondrinker.,family history: ,significant for high blood pressure and diabetes as well as cancer on her father side. he did pass away from congestive heart failure. mother suffers from high blood pressure, cancer, and diabetes. her mother has passed away secondary to cancer. she has two brothers one passed away from brain cancer.,review of systems: , significant for ankle swelling. the patient also wears glasses for vision and has dentures. she does complain of shortness of breath with exertion. she also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain. the patient denies ulcerative colitis, crohn disease, bleeding diathesis, liver disease, or kidney disease. she denies chest pain, cardiac disease, cancer, and stroke.,physical examination: ,the patient is a well-nourished, well-developed female, in no distress. eye exam: pupils equal and reactive to light. extraocular motions are intact. neck exam: no cervical lymphadenopathy. midline trachea. no carotid bruits. nonpalpable thyroid. neuro exam: gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted. lung exam: clear breath sounds without rhonchi or wheezes. cardiac exam: regular rate and rhythm without murmur or bruits. abdominal exam: positive bowel sounds. soft, nontender, obese, and nondistended abdomen. lap cholecystectomy scars noted. no obvious hernias. no organomegaly appreciated. lower extremity exam: edema 1+. dorsalis pedis pulses 2+.,assessment: ,the patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery. the patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,plan: , in preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels. i recommended the patient undergo an upper gi series prior to surgery due to find her upper gi anatomy. also the patient will meet with the dietitian and psychologist as per her usual routine. i have recommended approximately six to eight weeks of medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.

preoperative diagnosis: , postoperative hemorrhage.,postoperative diagnosis:, postoperative hemorrhage.,surgical procedure: ,examination under anesthesia with control of right parapharyngeal space hemorrhage.,anesthesia: ,general endotracheal technique.,surgical findings: , right lower pole bleeder cauterized with electrocautery with good hemostasis.,indications for surgery: , the patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy. previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty. however, in the pacu after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,description of surgery: ,the patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage. a crowe-davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized. there was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated. there was no other bleeding noted. the patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined. there was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery. no other bleeding was noted and the patient was recovered from general anesthetic. she was extubated and left the operating room in good condition to postoperative recovery room area. prior to extubation the patient's tonsillar fossa were injected with a 6 ml of 0.25% marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.

procedure: , eeg during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally. the eeg background is symmetric. independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region. no clinical signs of involuntary movements are noted during synchronous video monitoring. recording time is 22 minutes and 22 seconds. there is attenuation of the background, faster activity during drowsiness and some light sleep is recorded. no sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently. photic stimulation induced a bilaterally symmetric photic driving response.,impression:, eeg during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region. the eeg findings are consistent with potentially epileptogenic process. clinical correlation is warranted.

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.

procedure:, subcutaneous ulnar nerve transposition.,procedure in detail: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion. the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,a curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve. dissection was carried down to the ulnar nerve. branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized. six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,the subcutaneous plane just superficial to the flexor-pronator mass was developed. meticulous hemostasis was maintained with bipolar electrocautery. the nerve was transposed anteriorly, superficial to the flexor-pronator mass. motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,a semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating. the subcutaneous tissue and skin were closed with simple interrupted sutures. marcaine with epinephrine was injected into the wound. the elbow was dressed and splinted. the patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.

reason for visit: , i have been asked to see this 63-year-old man with a dilated cardiomyopathy by dr. x at abcd hospital. he presents with a chief complaint of heart failure.,history of present illness: , in retrospect, he has had symptoms for the past year of heart failure. he feels in general "ok," but is stressed and fatigued. he works hard running 3 companies. he has noted shortness of breath with exertion and occasional shortness of breath at rest. there has been some pnd, but he sleeps on 1 pillow. he has no edema now, but has had some mild leg swelling in the past. there has never been any angina and he denies any palpitations, syncope or near syncope. when he takes his pulse, he notes some irregularity. he follows no special diet. he gets no regular exercise, although he has recently started walking for half an hour a day. over the course of the past year, these symptoms have been slowly getting worse. he gained about 20 pounds over the past year.,there is no prior history of either heart failure or other heart problems.,his past medical history is remarkable for a right inguinal hernia repair done in 1982. he had trauma to his right thumb. there is no history of high blood pressure, diabetes mellitus or heart murmur.,on social history, he lives in san salvador with his wife. he has a lot of stress in his life. he does not smoke, but does drink. he has high school education.,on family history, mother is alive at age 89. father died at 72 of heart attack. he has 2 brothers and 1 sister all of whom are healthy, although the oldest suffered a myocardial infarction. he has 3 healthy girls and 9 healthy grandchildren.,a complete review of systems was performed and is negative aside from what is mentioned in the history of present illness.,medications: , aspirin 81 mg daily and chlordiazepoxide and clidinium - combination pill at 5 mg/2.5 mg 1 tablet daily for stress.,allergies: , denied.,major findings:, on my comprehensive cardiovascular examination, he is 5 feet 8 inches and weighs 231 pounds. his blood pressure is 120/70 in each arm seated. his pulse is 80 beats per minute and regular. he is breathing 1two times per minute and that is unlabored. eyelids are normal. pupils are round and reactive to light. conjunctivae are clear and sclerae are anicteric. there is no oral thrush or central cyanosis. neck is supple and symmetrical without adenopathy or thyromegaly. jugular venous pressure is normal. carotids are brisk without bruits. lungs are clear to auscultation and percussion. the precordium is quiet. the rhythm is regular. the first and second heart sounds are normal. he does have a fourth heart sound and a soft systolic murmur. the precordial impulse is enlarged. abdomen is soft without hepatosplenomegaly or masses. he has no clubbing, cyanosis or peripheral edema. distal pulses are normal throughout both arms and both legs. on neurologic examination, his mentation is normal. his mood and affect are normal. he is oriented to person, place, and time.,data: , his ekg shows sinus rhythm with left ventricular hypertrophy.,a metabolic stress test shows that he was able to exercise for 5 minutes and 20 seconds to 90% of his maximum predicted heart rate. his peak oxygen consumption was 19.7 ml/kg/min, which is consistent with mild cardiopulmonary disease.,laboratory data shows his tsh to be 1.33. his glucose is 97 and creatinine 0.9. potassium is 4.3. he is not anemic. urinalysis was normal.,i reviewed his echocardiogram personally. this shows a dilated cardiomyopathy with ef of 15%. the left ventricular diastolic dimension is 6.8 cm. there are no significant valvular abnormalities.,he had a stress thallium. his heart rate response to stress was appropriate. the thallium images showed no scintigraphic evidence of stress-induced myocardial ischemia at 91% of his maximum age predicted heart rate. there is a fixed small sized mild-to-moderate intensity perfusion defect in the distal inferior wall and apex, which may be an old infarct, but certainly does not account for the degree of cardiomyopathy. we got his post-stress ef to be 33% and the left ventricular cavity appeared to be enlarged. the total calcium score will put him in the 56 percentile for subjects of the same age, gender, and race/ethnicity.,assessments: , this appears to be a newly diagnosed dilated cardiomyopathy, the etiology of which is uncertain.,problems diagnoses: ,1. dilated cardiomyopathy.,2. dyslipidemia.,procedures and immunizations: , none today.,plans: , i started him on an ace inhibitor, lisinopril 2.5 mg daily, and a beta-blocker, carvedilol 3.125 mg twice daily. the dose of these drugs should be up-titrated every 2 weeks to a target dose of lisinopril of 20 mg daily and carvedilol 25 mg twice daily. in addition, he could benefit from a loop diuretic such as furosemide. i did not start this as he is planning to go back home to san salvador tomorrow. i will leave that up to his local physicians to up-titrate the medications and get him started on some furosemide.,in terms of the dilated cardiomyopathy, there is not much further that needs to be done, except for family screening. all of his siblings and his children should have an ekg and an echocardiogram to make sure they have not developed the same thing. there is a strong genetic component of this.,i will see him again in 3 to 6 months, whenever he can make it back here. he does not need a defibrillator right now and my plan would be to get him on the right doses of the right medications and then recheck an echocardiogram 3 months later. if his lv function has not improved, he does have new york heart association class ii symptoms and so he would benefit from a prophylactic icd.,thank you for asking me to participate in his care.,medication changes:, see the above.

history of present illness: , the patient is a 61-year-old female who was treated with cyberknife therapy to a right upper lobe stage ia non-small cell lung cancer. cyberknife treatment was completed one month ago. she is now being seen for her first post-cyberknife treatment visit.,since undergoing cyberknife treatment, she has had low-level nausea without vomiting. she continues to have pain with deep inspiration and resolving dysphagia. she has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,medications: , dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, tylenol with codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, spiriva q. day, combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, lidoderm patch every 12 hours, naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., megace 40 mg p.o. b.i.d., and asacol p.r.n.,physical examination: , bp: 122/86. temp: 96.8. hr: 79. rr: 26. ras: 100%.,heent: normocephalic. pupils are equal and reactive to light and accommodation. eoms intact.,neck: supple without masses or lymphadenopathy.,lungs: clear to auscultation bilaterally,cardiac: regular rate and rhythm without rubs, murmurs, or gallops.,extremities: no cyanosis, clubbing or edema.,assessment: , the patient has done well with cyberknife treatment of a stage ia non-small cell lung cancer, right upper lobe, one month ago.,plan: , she is to return to clinic in three months with a pet ct.

preoperative diagnoses:,1. radiation cystitis.,2. refractory voiding dysfunction.,3. status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,postoperative diagnoses:,1. radiation cystitis.,2. refractory voiding dysfunction.,3. status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,title of operation: , salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,anesthesia: , general endotracheal with epidural.,indications: ,this patient is a 65-year-old white male who in 1998 had a radical prostatectomy. he was initially dry without pads and then underwent salvage radiation therapy for rising psa. after that he began with episodes of incontinence as well as urinary retention requiring catheterization. one year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy. he had retained staple removed and a diverticulum identified. there were also bladder stones that were lasered and removed, and he had been incontinent ever since that time. he wears 8 to 10 pads per day, and this has affected his quality of life significantly. i took him to the operating room on january 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck. we both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him. i felt like if we could remove the bladder safely, then this would also provide a benefit.,findings: , at exploration, there were no gross lesions of the smaller or large bowel. the bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally. the opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment. because of the previous radiation therapy and a dissection down to the pelvis, i elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,procedure in detail: ,the patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion. a nasogastric tube was placed as well as radial arterial line. he was given intravenous antibiotics for prophylaxis. a generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described. moist wound towels and a bookwalter retractor were placed for exposure. we began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum. the ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips. an identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,we began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries. this was quite challenging because of the previous radiation therapy and radical prostatectomy. we essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally. we then approached things posteriorly and carefully dissected between the __________ and posterior bladder. there was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum. we then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum. we then peeled it off the remaining rectum and passed the specimen off the operative field. bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,we then completely mobilized the omentum off of the proximal transverse colon. this allowed a generous flap to be able to be laid into the pelvis without tension.,we then turned our attention to forming the indiana pouch. i completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon. the colon was divided proximal to the middle colic using a gia-80 stapler. i then divided the avascular plane of treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum. the mesentery was then sealed with a ligasure device and divided, and the bowel was divided with a gia-60 stapler. we then performed a side-to-side ileo-transverse colostomy using a gia-80 stapler, closing the open end with a ta 60. the angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,we then removed the staple line along the terminal ileum, passed a 12-french robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the gia-60 stapler. the ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by rowland, et al, and following this, passage of an 18-french robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,as the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy. we then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 vicryl sutures. the bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the sgia polysorb-75. between the staple lines, vicryl sutures were placed and the defects closed with 3-0 vicryl suture ligatures.,we then turned our attention to forming the ileocolonic anastomosis. the left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 vicryl sutures, and this was stented with a cook 8.4-french ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture. the right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis. we then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture. a 24-french malecot catheter was placed through the cecum and secured with a chromic suture. the staple lines were then buried with a running 3-0 vicryl two-layer suture and the open end of the pouch closed with a ta 60 polysorb suture. the pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,we then made a final inspection for hemostasis. the cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures. we then matured our stoma through the umbilicus. we removed the plug of skin through the umbilicus and delivered the ileal segment through this. a portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures. we left an 18-french robinson through the stomag and secured this to the skin with silk sutures. the malecot and stents were also secured in a similar fashion.,we matured the stoma to the umbilicus with interrupted chromic stitches. the stitch was brought out to the right upper quadrant and the malecot to the left lower quadrant. a large jp drain was placed in the pelvis dependent to the omentum pedicle flap as well as the indiana pouch.,the rectus fascia was closed with a buried #2 prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia. subcutaneous tissue was irrigated with saline and skin was closed with surgical clips. the estimated blood loss was 450 ml, and the patient received no packed red blood cells. the final sponge and needle count were reported to be correct. the patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.

preoperative diagnosis: , stenosing tendinosis, right thumb (trigger finger).,postoperative diagnosis: , stenosing tendinosis, right thumb (trigger finger).,procedure performed:, release of a1 pulley, right thumb.,anesthesia:, iv regional with sedation.,complications: , none.,estimated blood loss: , minimal.,tourniquet time: , approximately 20 minutes at 250 mmhg.,intraoperative findings: , there was noted to be thickening of the a1 pulley. there was a fibrous nodule noted within the flexor tendon of the thumb, which caused triggering sensation to the thumb.,history: ,this is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. she was actually able to spontaneously trigger the thumb. she was diagnosed with stenosing tendinosis and wishes to proceed with release of a1 pulley. all risks and benefits of the surgery was discussed with her at length. she was in agreement with the above treatment plan.,procedure: ,on 08/21/03, she was taken to operating room at abcd general hospital and placed supine on the operating table. a regional anesthetic was applied by the anesthesia department. tourniquet was placed on her proximal arm. the upper extremity was sterilely prepped and draped in the usual fashion.,an incision was made over the proximal crease of the thumb. subcuticular tissues were carefully dissected. hemostasis was controlled with electrocautery. the nerves were identified and retracted throughout the entire procedure. the fibers of the a1 pulley were identified. they were sharply dissected to release the tendon. the tendon was then pulled up into the wound and inspected. there was no evidence of gross tear noted. fibrous nodule was noted within the tendon itself. there was no evidence of continuous locking. once release of the pulley had been performed, the wound was copiously irrigated. it was then reapproximated using #5-0 nylon simple interrupted and horizontal mattress sutures. sterile dressing was applied to the upper extremity. tourniquet was deflated. it was noted that the thumb was warm and pink with good capillary refill. the patient was transferred to recovery in apparent stable and satisfactory condition. prognosis is fair.

exam: , ap abdomen and ultrasound of kidney.,history:, ureteral stricture.,ap abdomen ,findings:, comparison is made to study from month dd, yyyy. there is a left lower quadrant ostomy. there are no dilated bowel loops suggesting obstruction. there is a double-j right ureteral stent, which appears in place. there are several pelvic calcifications, which are likely vascular. no definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters. overall findings are stable versus most recent exam.,impression: , properly positioned double-j right ureteral stent. no evidence for calcified renal or ureteral stones.,ultrasound kidneys,findings:, the right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm. there is a right renal/ureteral stent identified. there is no perinephric fluid collection.,the left kidney demonstrates moderate-to-severe hydronephrosis. no stone or solid masses seen. the cortex is normal.,the bladder is decompressed.,impression:,1. left-sided hydronephrosis.,2. no visible renal or ureteral calculi.,3. right ureteral stent.

chief complaint: , "bloody bump on penis.",history of present illness: , this is a 29-year-old african-american male who presents to the emergency department today with complaint of a bleeding bump on his penis. the patient states that he has had a large bump on the end of his penis for approximately a year and a half. he states that it has never bled before. it has never caused him any pain or has never been itchy. the patient states that he is sexually active, but has been monogamous with the same person for the past 13 years. he states that he believes that his sexual partner is monogamous as well and reciprocates in this practice. the patient does state that last night he was "trying to get some," meaning that he was engaging in sexual intercourse, at which time this bump bent backwards and ripped a portion of the skin on the tip of his penis. the patient said that there is a large amount of blood from this injury. this happened last night, but he was embarrassed to come to the emergency department yesterday when it was bleeding. the patient has been able to get the bleeding to stop, but the large bump is still located on the end of his penis, and he is concerned that it will rip off, and does want it removed. the patient denies any drainage or discharge from his penis. he denies fevers or chills recently. he also denies nausea or vomiting. the patient has not had any discharge from his penis. he has not had any other skin lesions on his penis that are new to him. he states that he has had numerous bumps along the head of his penis and on the shaft of his penis for many years. the patient has never had these checked out. he denies fevers, chills, or night sweats. he denies unintentional weight gain or loss. he denies any other bumps, rashes, or lesions throughout the skin on his body.,past medical history: ,no significant medical problems.,past surgical history: , surgery for excision of a bullet after being shot in the back.,social habits: , the patient denies illicit drug usage. he occasionally smokes tobacco and drinks alcohol.,medications: , none.,allergies: , no known medical allergies.,physical examination: ,general: this is an african-american male who appears his stated age of 29 years. he is well nourished, well developed, in no acute distress. the patient is pleasant. he is sitting on a emergency department gurney.,vital signs: temperature 98.4 degrees fahrenheit, blood pressure of 139/78, pulse of 83, respiratory rate of 18, and pulse oximetry of 98% on room air.,heart: regular rate and rhythm. clear s1, s2. no murmur, rub, or gallop is appreciated.,lungs: clear to auscultation bilaterally. no wheezes, rales, or rhonchi.,abdomen: soft, nontender, nondistended, and positive bowel sounds throughout.,genitourinary: the patient's external genitalia is markedly abnormal. there is a large pedunculated mass dangling from the glans of the penis at approximately the urethral meatus. this pedunculated mass is approximately 1.5 x 2 cm in size and pedunculated by a stalk that is approximately 2 mm in diameter. the patient appears to have condylomatous changes along the glans of the penis and on the shaft of the penis as well. there are no open lesions at this point. there is a small tear of the skin where the mass attaches to the glans near the urethral meatus. bleeding is currently stanch, and there is no sign of secondary infection at this time. bilateral testicles are descended and normal without pain or mass bilaterally. there is no inguinal adenopathy.,extremities: no edema.,skin: warm, dry, and intact. no rash or lesion.,diagnostic studies: ,non-emergency department courses. it is thought that this patient should proceed directly with a referral to urology for excision and biopsy of this mass.,assessment and plan: , penile mass. the patient does have a large pedunculated penile mass. he will be referred to the urologist who is on-call today. the patient will need this mass excised and biopsied. the patient verbalized understanding the plan of followup and is discharged in satisfactory condition from the er.,

preoperative diagnoses:, ,1. spondylosis with cervical stenosis c5-c6 greater than c4-c5, c6-c7, (721.0, 723.0).,2. neck pain with left radiculopathy, progressive (723.1/723.4).,3. headaches, progressive (784.0).,postoperative diagnoses:, ,1. spondylosis with cervical stenosis c5-c6 greater than c4-c5, c6-c7, (721.0, 723.0).,2. neck pain with left radiculopathy, progressive (723.1/723.4).,3. headaches, progressive (784.0).,procedures:, ,1. anterior cervical discectomy at c5-c6 for neural decompression (63075).,2. anterior interbody fusion c5-c6 (22554) utilizing bengal cage (22851).,3. anterior cervical instrumentation at c5-c6 for stabilization by uniplate construction at c5-c6 (22845); with intraoperative x-ray x2.,service: , neurosurgery,anesthesia:,

preoperative diagnosis:, bilateral inguinal hernia. ,postoperative diagnosis: , bilateral inguinal hernia. ,procedure: , bilateral direct inguinal hernia repair utilizing phs system and placement of on-q pain pump. ,anesthesia: , general with endotracheal intubation. ,procedure in detail: , the patient was taken to the operating room and placed supine on the operating room table. general anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion. i did an ilioinguinal nerve block on both sides, injecting marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.

preoperative diagnosis: ,tailor's bunion and neuroma of the second and third interspace of the left foot.,postoperative diagnosis:, tailor's bunion and neuroma of the second and third interspace, left foot.,procedure performed:,1. tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2. excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3. excision of nerve lesion in the left third interspace.,anesthesia: ,monitored iv sedation with local.,history: ,this is a 37-year-old female who presents to abcd's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal. the patient has attempted conservative correction and injections with minimal improvement. the patient desires surgical correction at this time. the patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes. at this time, the patient desires surgical intervention and correction. the risks versus benefits of the procedure have been explained to the patient in detail by dr. x and consent was obtained.,procedure in detail: , after an iv was instituted by the department of anesthesia in the preoperative holding area, the patient was taken to the operating suite via cart and placed on the operating table in the supine position. a safety strap was placed across her waist for protection.,next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of webril for the patient's protection. after adequate iv sedation was administered by the department of anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% marcaine plain, and 1 cc of solu-medrol per 10 cc dose was administered to the patient for local anesthesia. the foot was then prepped and draped in the usual sterile orthopedic manner. the foot was then elevated and a tourniquet was then placed at 230 mmhg after applying esmarch bandage. the foot was then lowered down the operative field and sterile stockinet was draped. the stockinet was then reflected. attention was then directed to the second intermetatarsal interspace. after testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head. then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue. care was taken to identify and avoid or to cauterize any local encountered vascular structures. incision was deepened using the combination of blunt and dull dissection using mayo scissors, hemostat, and a #15 blade. the incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated. the individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly. these endings were dissected distally and cut at their most distal portions. following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space. using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue. this was also cut and removed. the proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed. following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection. it was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly. following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound. attention was then directed to the third interspace where in a manner as mentioned before. a dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head. like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,the incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal. the dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified. these were once again dissected distally out and transected at their most distal portions. care was then taken to dissect the nerve proximally into the proximal metatarsal region. no other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed. the proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace. half of the nerve was transected proximally as was feasible and no exposed ending was noted. incision was then flushed and irrigated using sterile saline. following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 vicryl and #4-0 nylon suture.,following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade. the incision was then deepened using #15 blade down to the level of the subcutaneous tissue. care was taken to reflect any neurovascular structures which were encountered. following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region. after adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially. following this, an orthosorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone. orthosorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position. following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally. following this, the periosteum was closed using #4-0 vicryl and the skin was closed in layers using #4-0 vicryl and closed with running subcuticular #4-0 monocryl suture. upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit. the incisions in foot were then ________ draped in the normal manner using owen silk, 4 x 4s, kling, and kerlix and covered with coban bandage. the tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmhg and immediate hyperemia was noted to end digits one through five of the left foot.,the patient was then transferred to the cart and was escorted to the postanesthesia care unit with vital signs stable and vascular status intact. the patient tolerated the procedure well without any complications. the patient was then given prescriptions for vicoprofen #30 and augmentin #14 to be taken twice daily. the patient was instructed to followup with dr. x after the weekend on tuesday in his office. the patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated. the patient also instructed to take her medications and prescriptions as directed. she was given the emergency contact numbers. postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.

exam: , left heart cath, selective coronary angiogram, right common femoral angiogram, and starclose closure of right common femoral artery.,reason for exam: , abnormal stress test and episode of shortness of breath.,procedure: , right common femoral artery, 6-french sheath, jl4, jr4, and pigtail catheters were used.,findings:,1. left main is a large-caliber vessel. it is angiographically free of disease,,2. lad is a large-caliber vessel. it gives rise to two diagonals and septal perforator. it erupts around the apex. lad shows an area of 60% to 70% stenosis probably in its mid portion. the lesion is a type a finishing before the takeoff of diagonal 1. the rest of the vessel is angiographically free of disease.,3. diagonal 1 and diagonal 2 are angiographically free of disease.,4. left circumflex is a small-to-moderate caliber vessel, gives rise to 1 om. it is angiographically free of disease.,5. om-1 is angiographically free of disease.,6. rca is a large, dominant vessel, gives rise to conus, rv marginal, pda and one pl. rca has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7. lvedp is measured 40 mmhg.,8. no gradient between lv and aorta is noted.,due to contrast concern due to renal function, no lv gram was performed.,following this, right common femoral angiogram was performed followed by starclose closure of the right common femoral artery.,impression:,1. 60% to 70% mid left anterior descending stenosis.,2. mild 30% to 40% stenosis of the proximal right coronary artery.,3. status post starclose closure of the right common femoral artery.,plan: ,plan will be to perform elective pci of the mid lad.

reason for consultation: , atrial fibrillation and shortness of breath.,history of presenting illness: , the patient is an 81-year-old gentleman. the patient had shortness of breath over the last few days, progressively worse. yesterday he had one episode and got concerned and came to the emergency room, also orthopnea and paroxysmal dyspnea. coronary artery disease workup many years ago. he also has shortness of breath, weakness, and tiredness.,coronary risk factors: , history of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status elevated, no history of established coronary artery disease, and family history positive.,family history: , positive for coronary artery disease.,surgical history: , knee surgery, hip surgery, shoulder surgery, cholecystectomy, and appendectomy.,medications: , thyroid supplementation, atenolol 25 mg daily, lasix, potassium supplementation, lovastatin 40 mg daily, and coumadin adjusted dose.,allergies: , aspirin.,personal history:, married, ex-smoker, and does not consume alcohol. no history of recreational drug use.,past medical history: , hypertension, hyperlipidemia, atrial fibrillation chronic, on anticoagulation.,surgical history: , as above.,presentation history: , shortness of breath, weakness, fatigue, and tiredness. the patient also relates history of questionable tia in 1994.,review of systems:,constitutional: weakness, fatigue, tiredness.,heent: no history of cataracts, blurry vision or glaucoma.,cardiovascular: arrhythmia, congestive heart failure, no coronary artery disease.,respiratory: shortness of breath. no pneumonia or valley fever.,gastrointestinal: nausea, no vomiting, hematemesis, or melena.,urological: some frequency, urgency, no hematuria.,musculoskeletal: arthritis, muscle weakness.,skin: chronic skin changes.,cns: history of tia. no cva, no seizure disorder.,endocrine: nonsignificant.,hematological: nonsignificant.,psychological: no anxiety or depression.,physical examination:,vital signs: pulse of 67, blood pressure 159/49, afebrile, and respiratory rate 18 per minute.,heent: atraumatic and normocephalic.,neck: neck veins flat. no significant carotid bruits.,lungs: air entry bilaterally fair, decreased in basal areas. no rales or wheezes.,heart: pmi displaced. s1 and s2 regular.,abdomen: soft and nontender. bowel sounds present.,extremities: chronic skin changes. pulses are palpable. no clubbing or cyanosis.,cns: grossly intact.,laboratory data: , h&h stable 30 and 39, inr of 1.86, bun and creatinine within normal limits, potassium normal limits. first set of cardiac enzymes profile negative. bnp 4810.,chest x-ray confirms unremarkable findings. ekg reveals atrial fibrillation, nonspecific st-t changes.,impression:

preoperative diagnosis:, comminuted fracture, dislocation left proximal humerus.,postoperative diagnosis:, comminuted fracture, dislocation left proximal humerus.,procedure performed: , hemiarthroplasty of left shoulder utilizing a global advantage system with an #8 mm cemented humeral stem and 48 x 21 mm modular head replacement.,procedure: ,the patient was taken to or #2, administered general anesthetic. he was positioned in the modified beach chair position on the operative table utilizing the shoulder apparatus. the left shoulder and upper extremities were then prepped and draped in the usual manner. a longitudinal incision was made extending from a point just lateral to the coracoid down towards deltoid tuberosity of the humerus. this incision was taken down through the skin and subcutaneous tissues were split utilizing the coag cautery. hemostasis was achieved with the cautery. the deltoid fascia were identified, skin flaps were then created. the deltopectoral interval was identified and the deltoid split just lateral to the cephalic vein. the deltoid was then retracted. there was marked hematoma and swelling within the subdeltoid bursa. this area was removed with rongeurs. the biceps tendon was identified which was the landmark for the rotator interval. mayo scissors was utilized to split the remaining portion of the rotator interval. the greater tuberosity portion with the rotator cuff was identified. excess bone was removed from the greater tuberosity side to allow for closure later. the lesser tuberosity portion with the subscapularis was still attached to the humeral head, therefore, osteotome was utilized to separate the lesser tuberosity from the humeral head fragment.,excess bone was removed from the lesser tuberosity as well. both of these were tagged with ethibond sutures for later. the humeral head was delivered out of the wound. it was localized to the area of the anteroinferior glenoid region. the glenoid was then inspected, and noted to be intact. the fracture was at the level of the surgical neck on the proximal humerus. the canal was repaired with the broaches. an #8 stem was chosen as it was going to be cemented into place. the trial stem was impacted into position and the shaft of the bone marked with the cautery to the appropriate retroversion. trial reduction was performed. the 48 x 21 mm head was the most appropriate size, matching the patient's as well as the soft tissue tension on the shoulder. at this point, the wound was copiously irrigated with gentamycin solution. the canal was copiously irrigated as well and suctioned dry. methyl methacrylate cement was mixed. the cement gun was filled and the canal was filled with the cement. the #8 stem was then impacted into place and held in the position in the appropriate retroversion until the cement had cured. excess cement was removed by sharp dissection. prior to cementation of the stem, a hole was drilled in the shaft of proximal humerus and #2 fiber wires were placed through this hole for closure later. once the cement was cured, the modular head was impacted on to the morse taper. it was stable and the shoulder was reduced. the lesser tuberosity was then reapproximated back to the original site utilizing the #2 fiber wire suture that was placed in the humeral shaft as well as the holes in the humeral implant. the greater tuberosity portion with rotator cuff was also attached to the implant as well as the shaft of the humerus utilizing #2 fiber wires as well. the rotator interval was closed with #2 fiber wire in an interrupted fashion. the biceps tendon was ________ within this closure. the wound was copiously irrigated with gentamycin solution, suctioned dry. the deltoid fascia was then approximated with interrupted #2-0 vicryl suture. subcutaneous layer was approximated with interrupted #2-0 vicryl and skin approximated with staples. subcutaneous tissues were infiltrated with 0.25% marcaine solution. a bulky dressing was applied to the wound followed by application of a large arm sling. circulatory status was intact in the extremity at the completion of the case. the patient was then transferred to recovery room in apparent satisfactory condition.

preoperative diagnoses:, multiparity requested sterilization and upper abdominal wall skin mass., ,postoperative diagnoses: ,multiparity requested sterilization and upper abdominal wall skin mass.,operation performed: , postpartum tubal ligation and removal of upper abdominal skin wall mass.,estimated blood loss:, less than 5 ml.,drains: , none.,anesthesia: , spinal.,indication: , this is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007. the patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,procedure in detail:, the patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department. the patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation. subumbilical ridge was created using two ellis and first knife was used to make a transverse incision. the ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed. the fascia grasped with two kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection. two army-navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with babcock's and followed to the fimbriated end. a modified pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized. adequate hemostasis was noted. this tube was placed back in its anatomic position. the right fallopian tube was grasped followed to its fimbriated end and then regrasped with a babcock and a modified pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position. the peritoneum as well as fascia was reapproximated with 0-vicryl. the subcutaneous tissues reapproximated with 3-0 vicryl and skin edges reapproximated with 4-0 vicryl as well in a subcuticular stitch. pressure dressings were applied. marcaine 10 ml was used prior to making an incision. sterile dressing was applied. the large mole-like lesion was grasped with allis. it was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 vicryl was used to reapproximate the skin edges and pressure dressing was also applied. instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.

past medical condition:, none.,allergies:, none.,current medication:, zyrtec and hydrocodone 7.5 mg one every 4 to 6 hours p.r.n. for pain.,chief complaint: , back injury with rle radicular symptoms.,history of present illness:, the patient is a 52-year-old male who is here for independent medical evaluation. the patient states that he works for abc abc as a temporary worker. he worked for abcd too. the patient's main job was loading and unloading furniture and appliances for the home. the patient was approximately there for about two and a half weeks. date of injury occurred back in october. the patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in october, he was unloading an 18-wheeler at abc and he was bending down picking up boxes to unload and load. unfortunately at this particular event, the patient had sharp pain in his lower back. soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. this became progressively worse. he also states that some of his radiating pain went down to his left leg as well. he noticed increase in buttock spasm and also noticed spasm in his buttocks. he initially saw dr. z and was provided with some muscle relaxer and was given some pain patches or lidoderm patch, i believe. the patient states that after this treatment, his symptoms still persisted. at this point, the patient later on was referred to dr. xyz through the workmen's comp and he was initially evaluated back in april. after the evaluation, the patient was sent for mri, was provided with pain medications such as short-acting opioids. he was put on restricted duty. the mri essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by dr. xyz in june with maximum medical improvement.,unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see dr. xyz again, and at this point, the patient was provided with further medication management and sent for pain clinic referral. the patient also was recommended for nerve block at this point and the patient received epidural steroid injection by dr. abc without any significant relief. the patient also was sent for emg and nerve conduction study, which was performed by dr. abcd and the mri, emg, and nerve conduction study came back essentially negative for radiculopathy, which was performed by dr. abcd. the patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. he has difficulty sleeping at nighttime because of increase in pain. ultimately, the patient was returned back to work in june, and deemed with maximum medical improvement back in june. the patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. the patient also went to see dr. x who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.,physical examination:, the patient was examined with the gown on. lumbar flexion was moderately decreased. extension was normal. side bending to the right was decreased. side bending to the left was within normal limits. rotation and extension to the right side was causing increasing pain. extension and side bending to the left was within normal limits without significant pain on the left side. while seated, straight leg was negative on the lle at 90° and also negative on the rle at 90°. there was no true root tension sign or radicular symptoms upon straight leg raising in the seated position. in supine position, straight leg was negative in the lle and also negative on the rle. sensory exam shows there was a decrease in sensation to the s1 dermatomal distribution on the right side to light touch and at all other dermatomal distribution was within normal limits. deep tendon reflex at the patella was 2+/4 bilaterally, but there was a decrease in reflex in the achilles tendon 1+/4 on the right side and essentially 2+/4 on the left side. medial hamstring reflex was 2+/4 on both hamstrings as well. on prone position, there was tightness in the paraspinals and erector spinae muscle as well as tightness on the right side of the quadratus lumborum area, right side was worse than the left side. increase in pain at deep palpatory examination in midline of the l5 and s1 level.,medical record review:, i had the opportunity to review dr. xyz's medical records. also reviewed dr. abc procedural note, which was the epidural steroid injection block that was performed in december. also, reviewed dr. x's medical record notes and an emg and nerve study that was performed by dr. abcd, which was essentially normal. the mri of the lumbar spine that was performed back in april, which showed no evidence of herniated disc.,diagnosis: , residual from low back injury with right lumbar radicular symptomatology.,evaluation/recommendation:, the patient has an impairment based on ama guides fifth edition and it is permanent. the patient appears to have re-aggravation of the low back injury back in october related to his work at abc when he was working unloading and loading an 18-wheel truck. essentially, there was a clear aggravation of his symptoms with ongoing radicular symptom down to his lower extremity mainly on the right side more so than the left. the patient also has increase in back pain with lumbar flexion and rotational movement to the right side. with these ongoing symptoms, the patient has also decrease in activities of daily living such as mobility as well as decrease in sleep pattern and general decrease in overall function. therefore, the patient is assigned 8% impairment of the whole person. we are able to assign this utilizing the fifth edition on spine section on the ama guide. using page 384, table 15-3, the patient does fall under dre lumbar category ii under criteria for rating impairment due to lumbar spine injury. in this particular section, it states that the patient's clinical history and examination findings are compatible with specific injury; and finding may include significant muscle guarding or spasm observed at the time of examination, a symmetric loss of range of motion, or non-verifiable radicular complaints define his complaints of radicular pain without objective findings; no alteration of the structural integrity and no significant radiculopathy. the patient also has decrease in activities of daily living; therefore, the patient is assigned at the higher impairment rating of 8% wpi. in the future, the patient should avoid prolonged walking, standing, stooping, squatting, hip bending, climbing, excessive flexion, extension, and rotation of his back. his one time weight limit should be determined by work trial, although the patient should continue to be closely monitored and managed for his pain control by the specific specialist for management of his overall pain. the patient although has a clear low back pain with certain movements such as stooping and extended sitting and does have a clear radicular symptomatology, the patient also should be monitored closely for specific dependency to short-acting opioids in the near future by specialist who could monitor and closely follow his overall pain management. the patient also should be treated with appropriate modalities and appropriate rehabilitation in the near future.,

exam: , ct head without contrast.,indications: , assaulted, positive loss of consciousness, rule out bleed.,technique: , ct examination of the head was performed without intravenous contrast administration. there are no comparison studies.,findings: ,there are no abnormal extraaxial fluid collections. there is no midline shift or mass effect. ventricular system demonstrates no dilatation. there is no evidence of acute intracranial hemorrhage. the calvarium is intact. there is a laceration in the left parietal region of the scalp without underlying calvarial fractures. the mastoid air cells are clear.,impression: ,no acute intracranial process.

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

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 upper eyelid squamous cell carcinoma.,postoperative diagnosis: , right upper eyelid squamous cell carcinoma.,procedure performed: , excision of right upper eyelid squamous cell carcinoma with frozen section and full-thickness skin grafting from the opposite eyelid.,complications: ,none.,blood loss: , minimal.,anesthesia:, local with sedation.,indication:, the patient is a 65-year-old male with a large squamous cell carcinoma on his right upper eyelid, which had previous radiation.,description of procedure: , the patient was taken to the operating room, laid supine, administered intravenous sedation, and prepped and draped in a sterile fashion. he was anesthetized with a combination of 2% lidocaine and 0.5% marcaine with epinephrine on both upper eyelids. the area of obvious scar tissue from the radiation for the squamous cell carcinoma on the right upper eyelid was completely excised down to the eyelid margin including resection of a few of the upper eye lashes. this was extended essentially from the punctum to the lateral commissure and extended up on to the upper eyelid. the resection was carried down through the orbicularis muscle resecting the pretarsal orbicularis muscle and the inferior portion of the preseptal orbicularis muscle leaving the tarsus intact and leaving the orbital septum intact. following complete resection, the patient was easily able to open and close his eyes as the levator muscle insertion was left intact to the tarsal plate. the specimen was sent to pathology, which revealed only fibrotic tissue and no evidence of any residual squamous cell carcinoma. meticulous hemostasis was obtained with bovie cautery and a full-thickness skin graft was taken from the opposite upper eyelid in a fashion similar to a blepharoplasty of the appropriate size for the defect in the right upper eyelid. the left upper eyelid incision was closed with 6-0 fast-absorbing gut interrupted sutures, and the skin graft was sutured in place with 6-0 fast-absorbing gut interrupted sutures. an eye patch was placed on the right side, and the patient tolerated the procedure well and was taken to pacu in good condition.

preoperative diagnosis,1. carpal tunnel syndrome.,2. de quervain's stenosing tenosynovitis.,postoperative diagnosis,1. carpal tunnel syndrome.,2. de quervain's stenosing tenosynovitis.,title of procedure,1. carpal tunnel release.,2. de quervain's release.,anesthesia: , mac,complications: , none.,procedure in detail: ,after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual standard fashion. the arm was exsanguinated with esmarch and the tourniquet inflated to 250 mmhg.,a longitudinal incision was made in line with the 4th ray, from kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease. the dissection was carried down to the superficial aponeurosis. the subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,the ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat. the hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat. the antebrachial fascia was cut proximally under direct vision with scissors.,after irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 vicryl. care was taken to avoid entrapping the motor branch of the median nerve in the suture. a hemostat was placed under the repair to ensure that the median nerve was not compressed. the skin was repaired with 5-0 nylon interrupted stitches.,the first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip. dissection was carried down with care taken to avoid and protect the superficial radial nerve branches. i released the compartment in a separate subsheath for the epb on the dorsal side. both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 vicryl. it was checked to make sure that there was significant room remaining for the tendons. this was done to prevent postoperative subluxation.,i then irrigated and closed the wounds in layers. marcaine with epinephrine was placed into all wounds, and dressings and splint were placed. the patient was sent to the recovery room in good condition, having tolerated the procedure well.

title of operation: , right frontal side-inlet ommaya reservoir.,indication for surgery: , the patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy. recommendation was for an ommaya reservoir. risks and benefits have been explained. they agreed to proceed.,preop diagnosis: , leukemic meningitis.,postop diagnosis: ,leukemic meningitis.,procedure detail: , the patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest. the right frontal region was prepped and draped in the usual sterile fashion. next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line. once this was completed, a burr hole was then created with a high-speed burr. the dura was then coagulated and opened. the ommaya reservoir catheter was inserted up to 6.5 cm. there was good flow. this was connected to the side inlet, flat-bottom ommaya and this was then placed in a subcutaneous pocket posterior to the incision. this was then cut and __________. it was then tapped percutaneously with 4 cubic centimeters and sent for routine studies. wound was then irrigated copiously with __________ irrigation, closed using 3-0 vicryl for the deep layers and 4-0 caprosyn for the skin. the connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.

operation performed:, phacoemulsification of cataract and posterior chamber lens implant, right eye., ,anesthesia:, retrobulbar nerve block, right eye, ,description of operation: ,the patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of betadine and a honan balloon. once anesthesia was achieved, the right eye was prepped with betadine, rinsed with saline, and draped in a sterile fashion. a lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe. a fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field. a surgical groove was applied with a 69 beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position. a lamellar dissection was carried anteriorly to clear cornea using a crescent knife. a stab incision was applied with a superblade at the 2 o'clock position at the limbus. the chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion. viscoat was injected into the chamber and an anterior capsulorrhexis performed. hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber. a deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision. a second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants. each quadrant was emulsified under burst power within the capsular bag. the epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power. i&a was used to aspirate cortex from the capsular bag. a scratcher was used to polish the capsule, and viscoat was injected inflating the capsular bag and chamber. the wound was enlarged with a shortcut blade to 5.5 mm. the intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag. the lens centralized nicely and viscoat was removed using the i&a. balanced salt was injected through the side-port incision. the wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera. the conjunctiva was pulled over the suture, and ancef 50 mg and decadron 4 mg were injected sub-tenon in the inferonasal and inferotemporal quadrants. maxitrol ointment was applied topically followed by an eye pad and shield. the patient tolerated the procedure and was taken from the operating room in good condition.

history of present illness: , mr. abc is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard bruce with horizontal st depressions and moderate apical ischemia on stress imaging only. he required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,the patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal lad with a severe mid-lad lesion of 99%, and a mid-left circumflex lesion of 80% with normal lv function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right pda.,i discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, i felt he was best suited for transfer for pci. i discussed the case with dr. x at medical center who has kindly accepted the patient in transfer.,condition on transfer: , stable but guarded. the patient is pain-free at this time.,medications on transfer:,1. aspirin 325 mg once a day.,2. metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3. nexium 40 mg once a day.,4. zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. i see that his ldl was 136 on may 3, 2002.,5. plavix 600 mg p.o. x1 which i am giving him tonight.,other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, gerd, arthritis,disposition: ,the patient and his wife have requested and are agreeable with transfer to medical center, and we are enclosing the cd rom of his images.

procedures performed:, phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves. botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,procedure codes: , 64640 times three, 64614 times four, 95873 times four.,preoperative diagnosis: , spastic quadriparesis secondary to traumatic brain injury, 907.0.,postoperative diagnosis:, spastic quadriparesis secondary to traumatic brain injury, 907.0.,anesthesia:, mac.,complications: , none.,description of technique: , informed consent was obtained from the patient's brother. the patient was brought to the minor procedure area and sedated per their protocol. the patient was positioned lying supine. skin overlying all areas injected was prepped with chlorhexidine. the obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active emg stimulation. approximately 7 ml was injected on the right side and 5 ml on the left side. at all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus. negative drawback for blood was done prior to each injection of phenol. the musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active emg stimulation. approximately 5 ml of 5% phenol was injected in this location. injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus. negative drawback for blood was done prior to each injection of phenol.,muscles injected with botulinum toxin were identified using active emg stimulation. approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors. total amount of botulinum toxin injected was 450 units diluted 25 units to 1 ml. the patient tolerated the procedure well and no complications were encountered.

chief complaint (1/1): ,this 24 year-old female presents today complaining of itchy, red rash on feet. associated signs and symptoms: associated signs and symptoms include tingling, right. context: patient denies any previous history, related trauma or previous treatments for this condition. duration: condition has existed for 4 weeks. location: she indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe. modifying factors: patient indicates ice improves condition. quality: quality of the itch is described by the patient as constant. severity: severity of condition is unbearable. timing (onset/frequency): onset was after leaving on sweaty socks.,allergies: , patient admits allergies to adhesive tape resulting in severe rash.,medication history:, none.,past medical history: , childhood illnesses: (+) chickenpox, (+) frequent ear infections.,past surgical history: ,patient admits past surgical history of ear tubes.,social history: , patient admits alcohol use drinking is described as social, patient denies tobacco use, patient denies illegal drug use, patient denies std history.,family history:, patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,review of systems:, unremarkable with exception of chief complaint.,physical exam: , bp sitting: 110/64 resp: 18 hr: 66 temp: 98.6,patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus. cardiovascular: skin temperature of the lower extremities is warm to cool, proximal to distal.,dp pulses palpable bilateral.,pt pulses palpable bilateral.,cft immediate.,no edema observed.,varicosities are not observed. skin: right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,neurological: touch, pin, vibratory and proprioception sensations are normal. deep tendon reflexes normal.,musculoskeletal: muscle strength is 5/5 for all groups tested. muscle tone is normal. inspection and palpation of bones, joints and muscles is unremarkable.,test results:, no tests to report at this time,impression: , tinea pedis.,plan: ,obtained fungal culture of skin from right toes. koh prep performed revealed no visible microbes.,prescriptions:, lotrimin af dosage: 1% cream sig: apply qid dispense: 4oz tube refills: 0 allow generic: yes

preoperative diagnoses:,1. vault prolapse.,2. enterocele.,preoperative diagnoses:,1. vault prolapse.,2. enterocele.,operations:,1. abdominosacrocolpopexy.,2. enterocele repair.,3. cystoscopy.,4. lysis of adhesions.,anesthesia: , general endotracheal.,estimated blood loss:, less than 100 ml.,specimen: , none.,brief history:, the patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse. the patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse. options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,the patient already had multiple abdominal scars. risk of open surgery was little bit higher for the patient. after discussing the options the patient wanted to proceed a pfannenstiel incision and repair of the sacrocolpopexy. risks of anesthesia, bleeding, infection, pain, mi, dvt, pe, mesh erogenic exposure, complications with mesh were discussed. the patient understood the risks of recurrence, etc, and wanted to proceed with the procedure. the patient was told to perform no heavy lifting for 3 months, etc. the patient was bowel prepped, preoperative antibiotics were given.,details of the operation: , the patient was brought to the or, anesthesia was applied. the patient was placed in dorsal lithotomy position. the patient was prepped and draped in usual sterile fashion. a pfannenstiel low abdominal incision was done at the old incision site. the incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle. the muscle was split in the middle and peritoneum was entered using sharp mets. there was no injury to the bowel upon entry. there were significant adhesions which were unleashed. all the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized. there was minimal space, everything was packed, bookwalter placed then over the sacral bone. the middle of the sacral bone was identified. the right ureter was clearly identified and was lateral to where the posterior peritoneum was opened. the ligament over the sacral or sacral __________ was easily identified, 0 ethibond stitches were placed x3. a 1 cm x 5 cm mesh was cut out. this was a prolene soft mesh which was tied at the sacral ligament. the bladder was clearly off the vault area which was exposed, in the raw surface 0 ethibond stitches were placed x3. the mesh was attached. the apex was clearly up enterocele sac was closed using 4-0 vicryl without much difficulty. the ureter was not involved at all in this process. the peritoneum was closed over the mesh. please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel. prior to closure antibiotic irrigation was done using ancef solution. the mesh has been exposed in antibiotic solution prior to the usage.,after a through irrigation with l and half of antibiotic solution. all the solution was removed. good hemostasis was obtained. all the packing was removed. count was correct. rectus abdominus muscle was brought together using 4-0 vicryl. the fascia was closed using loop #1 pds in running fascia from both sides and was tied in the middle. subcutaneous tissue was closed using 4-0 vicryl and the skin was closed using 4-0 monocryl in subcuticular fashion. cystoscopy was done at the end of the procedure. please note that the foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure. cystoscopy was done and indigo carmine has been given. there was good efflux of indigo carmine in both of the ureteral opening. there was no injury to the rectum or the bladder. the bladder appeared completely normal. the rectal exam was done at the end of the procedure after the cystoscopy. after the cysto was done, the scope was withdrawn, foley was placed back. the patient was brought to recovery in the stable condition.

nuclear cardiology/cardiac stress report,indication for study: , recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,procedure: , the patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes. at completion of the second minute of infusion, the patient received technetium cardiolite per protocol. during this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion. no diagnostic electrocardiographic abnormalities were elaborated during this study.,regional myocardial perfusion with adenosine provocation: , scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time. a fixed defect is seen in the high anterolateral segment. a further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum. there is no evidence for active ischemia in either distribution. lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity. when viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall. a limited segment of apical myocardium is still viable.,no gated wall motion study was obtained.,conclusions: ,cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above. there is no indication for active ischemia at this time.

chief complaint:, intractable nausea and vomiting.,history of present illness:, this is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. she has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. she also has had multiple endoscopies revealing gastritis and esophagitis. she has been noted in the past multiple times to be medically noncompliant with her medication regimen. she also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in january, 2006. she presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. she was discharged on reglan and high-dose ppi yesterday, and was instructed to take all of her medications as prescribed. she states that she has been compliant, but her symptoms have not been controlled. it should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,past medical history:,1. diabetes mellitus (poorly controlled).,2. hypertension (poorly controlled).,3. chronic renal insufficiency.,4. adrenal mass.,5. obstructive sleep apnea.,6. arthritis.,7. hyperlipidemia.,past surgical history:,1. removal of ovarian cyst.,2. hysterectomy.,3. multiple egds with biopsies over the last six years. her last egd was in june, 2005, which showed esophagitis and gastritis.,4. colonoscopy in june, 2005, showing diverticular disease.,5. cardiac catheterization in february, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. laparoscopic adrenalectomy in january, 2006.,medications:,1. reglan 10 mg orally every 6 hours.,2. nexium 20 mg orally twice a day.,3. labetalol.,4. hydralazine.,5. clonidine.,6. lantus 20 units at bedtime.,7. humalog 30 units before meals.,8. prozac 40 mg orally daily.,social history:, she has a 27 pack year smoking history. she denies any alcohol use. she does have a history of chronic marijuana use.,family history:, significant for diabetes and hypertension.,allergies:, no known drug allergies.,review of systems:,heent: see has had headaches, and some dizziness. she denies any vision changes.,cardiac: she denies any chest pain or palpitations.,respiratory: she denies any shortness of breath.,gi: she has had persistent nausea and vomiting. she denies diarrhea, melena or hematemesis.,neurological: she denies any neurological deficits.,all other systems were reviewed and were negative unless otherwise mentioned in hpi.,physical examination:,vital signs: blood pressure: 220/130. heart rate: 113. respiratory rate: 18. temperature: 98.,general: this is a 43-year-old obese african-american female who appears in no acute distress. she has a depressed mood and flat affect, and does not answer questions elaborately. she will simply state that she does not feel well.,heent: normocephalic, atraumatic, anicteric. perrla. eomi. mucous membranes moist. oropharynx is clear.,neck: supple. no jvd. no lymphadenopathy.,lungs: clear to auscultation bilaterally, nonlabored.,heart: regular rate and rhythm. s1 and s2. no murmurs, rubs, or gallops.

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

history of present illness: , the patient is a 41-year-old white male with a history of hiv disease. his last cd4 count was 425, viral load was less than 50 in 08/07. he was recently hospitalized for left gluteal abscess, for which he underwent i&d and he has newly diagnosed diabetes mellitus. he also has a history of hypertension and hypertriglyceridemia. he had been having increased urination and thirst. he was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess. the endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on glucophage and glyburide. the patient reports that he has been taking the medication. he is in general feeling better. he says that his gluteal abscess is improving and he will be following up with surgery today.,current medications:,1. gabapentin 600 mg at night.,2. metformin 1000 mg twice a day.,3. glipizide 5 mg a day.,4. flagyl 500 mg four times a day.,5. flexeril 10 mg twice a day.,6. paroxetine 20 mg a day.,7. atripla one at night.,8. clonazepam 1 mg twice a day.,9. blood pressure medicine, name unknown.,review of systems:, he otherwise has a negative review of systems.,physical examination:,vital signs: temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.) heent: unremarkable except for some submandibular lymph nodes. his fundi are benign. neck: supple. lungs: clear to auscultation and percussion. cardiac: reveals regular rate and rhythm without murmur, rub or gallop. abdomen: soft and nontender without organomegaly or mass. extremities: show no cyanosis, clubbing or edema. gu: examination of the perineum revealed an open left gluteal wound that appears clear with no secretions.,impression:,1. human immunodeficiency virus disease with stable control on atripla.,2. resolving left gluteal abscess, completing flagyl.,3. diabetes mellitus, currently on oral therapy.,4. hypertension.,5. depression.,6. chronic musculoskeletal pain of unclear etiology.,plan: , the patient will continue his current medications. he will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter. he has been encouraged to keep his appointment with his psychologist.

diagnosis: , left knee osteoarthritis.,history: , the patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis. the patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area. the patient was transferred from the hospital to a nursing home and lived there for 1 year. prior to this incident, the patient was ambulating independently with a pickup walker throughout her home. since that time, the patient has only been performing transverse and has been unable to ambulate. the patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.,past medical history: , high blood pressure, obesity, right patellar fracture with pin in 1990, and history of blood clots.,medications: ,naproxen, plavix, and stool softener.,medical diagnostics: , the patient states that she had an x-ray of the knee in 2007 and was diagnosed with osteoarthritis.,subjective:, the patient reports that when seated and at rest, her knee pain is 0/10. the patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.,patient's goal: , to transfer better and walk 5 feet from her bed to the couch.,inspection: , the right knee has a large 8-inch long and very wide tight scar with adhesions to the underlying connective tissue due to her patellar fracture and surgery following an mva in 1990, bilateral knees are very large due to obesity. there are no scars, bruising or increased temperature noted in the left knee.,range of motion: , active and passive range of motion of the right knee is 0 to 90 degrees and the left knee, 0 to 85 degrees. pain is elicited during active range of motion of the left knee.,palpation: , palpation to the left knee elicits pain around the patellar tendon and to each side of this area.,functional mobility: ,the patient reports that she transfers with standby to contact-guard assist in the home from her bed to her wheelchair and return. the patient is able to stand modified independent from wheelchair level and tolerates at least 15 seconds of standing prior to needing to sit down due to the left knee pain.,assessment: ,the patient is a 58-year-old female with left knee osteoarthritis. examination indicates deficits in pain, muscle endurance, and functional mobility. the patient would benefit from skilled physical therapy to address these impairments.,treatment plan: ,the patient will be seen two times per week for an initial 4 weeks with re-assessment at that time for an additional 4 weeks if needed.,interventions include:,1. modalities including electrical stimulation, ultrasound, heat, and ice.,2. therapeutic exercise.,3. functional mobility training.,4. gait training.,long-term goals to be achieved in 4 weeks:,1. the patient is to have increased endurance in bilateral lower extremities as demonstrated by being able to perform 20 repetitions of all lower extremity exercises in seated and supine positions with minimum 2-pound weight.,2. the patient is to perform standby assist transfer using a pickup walker.,3. the patient is to demonstrate 4 steps of ambulation using forward and backward using a pickup walker or front-wheeled walker.,4. the patient is to report maximum 3/10 pain with weightbearing of 2 minutes in the left knee.,long-term goals to be achieved in 8 weeks:,1. the patient is to be independent with the home exercise program.,2. the patient is to tolerate 20 reps of standing exercises with pain maximum of 3/10.,3. the patient is to ambulate 20 feet with the most appropriate assistive device.,prognosis to the above-stated goals:, fair to good.,the above treatment plan has been discussed with the patient. she is in agreement.

diagnoses:,1. disseminated intravascular coagulation.,2. streptococcal pneumonia with sepsis.,chief complaint: , unobtainable as the patient is intubated for respiratory failure.,current history of present illness: , this is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. at this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated d-dimer. at this time, i am being consulted for further evaluation and recommendations for treatment. the nurses report that she has actually improved clinically over the last 24 hours. bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. there is no prior history of coagulopathy.,past medical history: ,otherwise nondescript as is the past surgical history.,social history: ,there were possible illicit drugs. her family is present, and i have discussed her case with her mother and sister.,family history: ,otherwise noncontributory.,review of systems: , not otherwise pertinent.,physical examination:,general: she is a sedated, young black female in no acute distress, lying in bed intubated.,vital signs: she has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,heent: her sclerae showed conjunctival hemorrhage. there are no petechiae. her nasal vestibules are clear. oropharynx has et tube in place.,neck: no jugular venous pressure distention.,chest: coarse breath sounds bilaterally.,heart: regular rate and rhythm.,abdomen: soft and nontender with good bowel sounds. there was some oozing around the site of her central line.,extremities: no clubbing, cyanosis, or edema. there is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,laboratory studies: ,the dic parameters with a platelet count of approximately 50,000, inr of 2.4, normal ptt at this time, fibrinogen of 200, and a d-dimer of 13.,impression/plan: ,at this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. my recommendation for the patient is to continue factor replacement as you are. it seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. there is no indication at this point for xigris. however, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, i would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. i will repeat her laboratory studies in the morning and give more recommendations at that time.

preoperative diagnoses:,1. benign prostatic hypertrophy.,2. urinary retention.,postoperative diagnoses:,1. benign prostatic hypertrophy.,2. urinary retention.,procedure performed:,1. cystourethroscopy.,2. transurethral resection of prostate (turp).,anesthesia: ,spinal.,drain: , a #24 french three-way foley catheter.,specimens: , prostatic resection chips.,estimated blood loss: ,150 cc.,disposition: ,the patient was transferred to the pacu in stable condition.,indications and findings: ,this is an 84-year-old male with history of bph and subsequent urinary retention with failure of trial of void, scheduled for elective turp procedure.,findings: , at the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe. cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,description of procedure: , after informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the department of anesthesia. the patient was prepped and draped in the normal sterile fashion and a #21 french cystoscope inserted into urethra and into the bladder. cystoscopy performed with the above findings. cystoscope was removed. a #27 french resectoscope with a #26 cutting loop was inserted into the bladder. verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed. ________ irrigator was used to evacuate the bladder of prostatic chips. resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop. any obvious bleeding from the prostatic fossa was controlled with electrocautery. resectoscope was removed. a #24 french three-way foley catheter inserted into the urethra and into the bladder. bladder was irrigated and connected to three-way irrigation. the patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.

chief complaint:, lump in the chest wall.,history of present illness: , this is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. it is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.,chronic/inactive conditions,1. hypertension.,2. hyperlipidemia.,3. glucose intolerance.,4. chronic obstructive pulmonary disease?,5. tobacco abuse.,6. history of anal fistula.,illnesses:, see above.,previous operations: , anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery.,previous injuries: , he had a broken ankle in the past. they questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. he said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. he told me that he hit a moose once, but he does not remember hitting his chest.,allergies: , to bactrim, simvastatin, and cipro.,current medications,1. lisinopril.,2. metoprolol.,3. vitamin b12.,4. baby aspirin.,5. gemfibrozil.,6. felodipine.,7. levitra.,8. pravastatin.,family history: , positive for hypertension, diabetes, and cancer. negative for heart disease, obesity or stroke.,social history: ,the patient is married. he works as a truck driver and he drives in town. he smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.,review of systems,constitutional: denies weight loss/gain, fever or chills.,enmt: denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision.,cv: see history of present illness. denies chest pain, sob supine, palpitations, edema, varicose veins or leg pains.,respiratory: he has a chronic cough. denies shortness of breath, wheezing, sputum production or bloody sputum.,gi: denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation.,gu: denies painful/burning urination, cloudy/dark urine, flank pain or groin pain.,ms: denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness.,neuro: denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis.,psych: denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts.,integumentary: denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration.,physical examination,constitutional: blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. the patient is well developed, well nourished, and with fair attention to grooming. the patient is moderately overweight.,neck: the neck is symmetric, the trachea is in the midline, and there are no masses. no crepitus is palpated. the thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,respiration: normal respiratory effort. there is no intercostal retraction or action by the accessory muscles. normal breath sounds bilaterally with no rhonchi, wheezing or rubs. there is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum.,cardiovascular: the pmi is palpable at the 5ics in the mcl. no thrills on palpation. s1 and s2 are easily audible. no audible s3, s4, murmur, click, or rub. carotid pulses 2+ without bruits. abdominal aorta is not palpable. no audible abdominal bruits. femoral pulses are 2+ bilaterally, without audible bruits. extremities show no edema or varicosities.