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chief complaint: , chest pain and fever.,history of present illness: , this 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin. the patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating. the patient does have a past medical history of diabetes and hypertension. in addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well. the patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits. she has not had any musculoskeletal or neurological deficits. she denies any rashes or skin lesions.,past medical history: ,hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated ldl at 81 with an new standard ldl of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,past surgical history: ,cholecystectomy, appendectomy, oophorectomy.,family history: , positive for coronary artery disease in her father and brother in their 40s.,social history: , she is married and does not smoke or drink nor did she ever.,physical examination: , on admission, temperature 99.4 degrees f., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort. in general, she is well developed, well nourished, oriented, and alert and in no apparent distress. head, ears, eyes, nose, and throat are unremarkable. neck is supple. no neck vein distention is noted. no bruits are heard. chest is clear to percussion and auscultation. heart has a regular rhythm and rate without murmurs or rubs or gallops. abdomen is soft, obese, and nontender. musculoskeletal is intact without deformity. however, the patient did develop severe cramp behind her left knee during her treadmill testing. neurologic: cranial nerves are intact and she is nonfocal. skin is warm and dry without rash or lesions noted.,laboratory findings: , glucose 162, bun 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2. liver function panel is normal. ck was 82. mb fraction was 1.0. troponin was less than 0.1 on three occasions. white count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000. urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods. spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0. ekg was normal.,diagnoses on admission:,1. urinary tract infection.,2. chest pain of unclear etiology, rule out myocardial infarction.,3. neck and back pain of unclear etiology with a negative spinal tap.,4. hypertension.,5. diabetes type ii, not treated with insulin.,6. hyperlipidemia treated with tricor but not statins.,7. arthritis.,additional laboratory studies:, b-natriuretic peptide was 26. urine smear and culture negative on 24 and 48 hours. chest x-ray was negative. lipid panel - triglycerides 249, vldl 49, hdl 33, ldl 81.,course in the hospital: , the patient was placed on home medications. this will be listed at the end of the discharge summary. she was put on rule out acute myocardial infarction routine, and she did in fact rule out. she had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to uti, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an ldl elevated to 81 with new normal being less than 70. she has a strong family history of early myocardial disease in the men in their 40s.,discharge medications:,1. enteric-coated aspirin 81 mg one daily. this is new, as the patient was not taking aspirin at home.,2. tricor 48 mg one daily.,3. zantac 40 mg one daily.,4. lisinopril 20 mg one daily.,5. mobic 75 mg one daily for arthritis.,6. metformin 500 mg one daily.,7. macrodantin one two times a day for several more days.,8. zocor 20 mg one daily, which is a new addition.,9. effexor xr 37.5 mg one daily.,diet: , ada 1800-calorie diet.,activity:, as tolerated. continue water exercise five days a week.,disposition: , recheck at hospital with a regular physician there in 1 week. consider byetta as an adjunct to her diabetic treatment and efforts to weight control.

chief complaint: , increased work of breathing.,history of present illness: , the patient is a 2-month-old female with a 9-day history of illness. per mom's report, the illness started 9 days ago with a dry cough. the patient was eating normal up until approximately three days ago. mom was using a vaporizer at night, which she feels to have helped. the patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. at that time, the patient also had significant increasing congestion. two days ago the patient was taken to the primary care physician's office and the patient was given xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. on wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. the patient was brought to children's hospital emergency room at which time the patient was evaluated. a chest x-ray was obtained and was noted to be normal. the patient's saturations were noted to be normal and the patient was discharged home. last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. the patient had a 101 temperature on wednesday evening, but has had no true fevers. the patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to children's hospital for reevaluation.,review of systems: , the remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,allergies:, no known drug allergies.,medications: ,as above.,immunizations:, none.,past medical history: ,no hospitalizations. no surgeries.,birth history: , the patient was born to a g8, p2, a6 mom via normal spontaneous vaginal delivery. birth weight 6 pounds 12 ounces. mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. the patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,family history: , brother, mother, and father all have asthma. mom was noted to have gestational diabetes.,social history: , the patient lives with mother, father, and a brother. there is one bird. there are smokers in the household. there are sick contacts.,physical examination:,vital signs: temperature is 97.7 and pulse is 181, but the patient is fussy. respiratory rate ranged between 36 and 44. the patient is saturating 100% on one-half liter and 89% on room air.,general appearance: nontoxic child, but with increased work of breathing. no respiratory distress.,heent: head is normocephalic and atraumatic. anterior fontanelle flat. pupils are equal, round, and reactive to light bilaterally. tympanic membranes are clear bilaterally. nares are congested. mucous membranes are moist without erythema.,neck: supple. no lymphadenopathy.,chest: exhibits symmetric expansion and retractions.,lungs: the patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,cardiovascular: heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,abdomen: soft, nondistended, and nondistended. good bowel sounds noted in all 4 quadrants.,gu: normal female. no discharge or erythema.,back: normal with a normal curvature.,extremities: a 2+ pulses in the bilateral upper lower extremities. no evidence of clubbing, cyanosis, or edema. capillary refill less than 3 seconds.,laboratory data: , labs in the emergency room include a cbc, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. a urinalysis obtained in the emergency room was noted to be negative. crp was noted to be 2.0. the chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,assessment and plan: , this is a 2-month-old female who presents to children's hospital with examination consistent with bronchiolitis. at this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. currently, at this time, i feel no respiratory treatments are indicated in this patient. i hear no evidence of wheezing or reactive airway disease. we will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.

problem: ,rectal bleeding, positive celiac sprue panel.,history: ,the patient is a 19-year-old irish-greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits. she noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody. she has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved. she actually has none of these symptoms since starting her gluten-free diet. she has noted intermittent rectal bleeding with constipation, on the toilet tissue. she feels remarkably better after starting a gluten-free diet.,allergies: , no known drug allergies.,operations: , she is status post a tonsillectomy as well as ear tubes.,illnesses: , questionable kidney stone.,medications: , none.,habits: , no tobacco. no ethanol.,social history: , she lives by herself. she currently works in a dental office.,family history: , notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well. she has two sisters and one brother. one sister interestingly has inflammatory arthritis.,review of systems: ,notable for fever, fatigue, blurred vision, rash and itching; her gi symptoms that were discussed in the hpi are actually resolved in that she started the gluten-free diet. she also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination. please see symptoms summary sheet dated april 18, 2005.,physical examination: , general: she is a well-developed pleasant 19 female. she has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds. she has anicteric sclerae. pink conjunctivae. perrla. ent: mmm. neck: supple. lungs: clear to auscultation.

reason for admission:, intraperitoneal chemotherapy.,history: , a very pleasant 63-year-old hypertensive, nondiabetic, african-american female with a history of peritoneal mesothelioma. the patient has received prior intravenous chemotherapy. due to some increasing renal insufficiency and difficulties with hydration, it was elected to change her to intraperitoneal therapy. she had her first course with intraperitoneal cisplatin, which was very difficultly tolerated by her. therefore, on the last hospitalization for ip chemo, she was switched to taxol. the patient since her last visit has done relatively well. she had no acute problems and has basically only chronic difficulties. she has had some decrease in her appetite, although her weight has been stable. she has had no fever, chills, or sweats. activity remains good and she has continued difficulty with depression associated with type 1 bipolar disease. she had a recent ct scan of the chest and abdomen. the report showed the following findings. in the chest, there was a small hiatal hernia and a calcification in the region of the mitral valve. there was one mildly enlarged mediastinal lymph node. several areas of ground-glass opacity were noted in the lower lungs, which were subtle and nonspecific. no pulmonary masses were noted. in the abdomen, there were no abnormalities of the liver, pancreas, spleen, and left adrenal gland. on the right adrenal gland, a 17 x 13 mm right adrenal adenoma was noted. there were some bilateral renal masses present, which were not optimally evaluated due to noncontrast study. a hyperdense focus in the lower pole of the left kidney was felt to most probably represent a hemorrhagic renal cyst. it was unchanged from february and measured 9 mm. there was again minimal left pelvic/iliac _______ with right and left peritoneal catheters noted and were unremarkable. mesenteric nodes were seen, which were similar in appearance to the previous study that was felt somewhat more conspicuous due to opacified bowel adjacent to them. there was a conglomerate omental mass, which had decreased in volume when compared to previous study, now measuring 8.4 x 1.6 cm. in the pelvis, there was a small amount of ascites in the right pelvis extending from the inferior right paracolic gutter. no suspicious osseous lesions were noted.,current medications: , norco 10 per 325 one to two p.o. q.4h. p.r.n. pain, atenolol 50 mg p.o. b.i.d., levoxyl 75 mcg p.o. daily, phenergan 25 mg p.o. q.4-6h. p.r.n. nausea, lorazepam 0.5 mg every 8 hours as needed for anxiety, ventolin hfa 2 puffs q.6h. p.r.n., plavix 75 mg p.o. daily, norvasc 10 mg p.o. daily, cymbalta 60 mg p.o. daily, and restoril 30 mg at bedtime as needed for sleep.,allergies: , the patient states that on occasion lorazepam dose produce hallucinations, and she had difficulty tolerating ativan.,physical examination,vital signs: the patient's height is 165 cm, weight is 77 kg. bsa is 1.8 sq m. the vital signs reveal blood pressure to be 158/75, heart rate 61 per minute with a regular sinus rhythm, temperature of 96.6 degrees, respiratory rate 18 with an spo2 of 100% on room air.,general: she is normally developed; well nourished; very cooperative; oriented to person, place, and time; and in no distress at this time. she is anicteric.,heent: eom is full. pupils are equal, round, reactive to light and accommodation. disc margins are unremarkable as are the ocular fields. mouth and pharynx within normal limits. the tms are glistening bilaterally. external auditory canals are unremarkable.,neck: supple, nontender without adenopathy. trachea is midline. there are no bruits nor is there jugular venous distention.,chest: clear to percussion and auscultation bilaterally.,heart: regular rate and rhythm without murmur, gallop, or rub.,breasts: unremarkable.,abdomen: slightly protuberant. bowel tones are present and normal. she has no palpable mass, and there is no hepatosplenomegaly.,extremities: within normal limits.,neurological: nonfocal.,diagnostic impression,1. intraperitoneal mesothelioma, partial remission, as noted by ct scan of the abdomen.,2. presumed left lower pole kidney hemorrhagic cyst.,3. history of hypertension.,4. type 1 bipolar disease.,plan: , the patient will have appropriate laboratory studies done. a left renal ultrasound is requested to further delineate the possible hemorrhagic cyst in the lower left pole of the left kidney. interventional radiology will access for ports in the abdomen. she will receive chemotherapy intraperitoneally. the plan will be to use intraperitoneal taxol.

exam: , ct abdomen and pelvis with contrast ,reason for exam:, nausea, vomiting, diarrhea for one day. fever. right upper quadrant pain for one day. ,comparison: , none. ,technique:, ct of the abdomen and pelvis performed without and with approximately 54 ml isovue 300 contrast enhancement. ,ct abdomen: , lung bases are clear. the liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. the aorta is normal in caliber. there is no retroperitoneal lymphadenopathy. ,ct pelvis: , the appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. per ct, the colon and small bowel are unremarkable. the bladder is distended. no free fluid/air. visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,impression:,1. unremarkable exam; specifically no evidence for acute appendicitis. ,2. no acute nephro-/ureterolithiasis. ,3. no secondary evidence for acute cholecystitis.,results were communicated to the er at the time of dictation.

procedure performed: , egd with biopsy.,indication: , mrs. abc is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago. she was admitted because of recurrent nausea and vomiting, with displacement of the gej feeding tube. a ct scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach. the endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms. physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,medications: , fentanyl 25 mcg, versed 2 mg, 2% lidocaine spray to the pharynx.,instrument: , gif 160.,procedure report:, informed consent was obtained from mrs. abc's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications. consent was not obtained from mrs. morales due to her recent narcotic administration. conscious sedation was achieved with the patient lying in the left lateral decubitus position. the endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,findings:,1. esophagus: there was evidence of grade c esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length. multiple biopsies were obtained from this region and placed in jar #1.,2. stomach: small hiatal hernia was noted within the cardia of the stomach. there was an indentation/scar from the placement of the previous peg tube and there was suture material noted within the body and antrum of the stomach. the remainder of the stomach examination was normal. there was no feeding tube remnant seen within the stomach.,3. duodenum: this was normal.,complications:, none.,assessment:,1. grade c esophagitis seen within the distal, mid, and proximal esophagus.,2. small hiatal hernia.,3. evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,plan: , followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.

chief complaint: , worsening seizures.,history of present illness: ,a pleasant 43-year-old female with past medical history of cp since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity. the patient stated she was in her normal state of well being when she was experiencing having frequent seizures. she lives in assisted living. she has been falling more frequently. the patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this. there was no head trauma, but apparently she was doing that many times and there was no responsiveness. the patient has no memory of the event. she is now back to her baseline. she states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred. she is on carbatrol 300 mg b.i.d. and she has been very compliant and without any problems. the patient is admitted for emu monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,past medical history: ,include dyslipidemia and hypertension.,family history: ,positive for stroke and sleep apnea.,social history: , no smoking or drinking. no drugs.,medications at home: , include, avapro, lisinopril, and dyslipidemia medication, she does not remember.,review of systems:, the patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning. the patient also has excessive daytime sleepiness with eds of 16.,physical examination:,vital signs: last blood pressure 130/85, respirations 20, and pulse 70.,general: normal.,neurological: as follows. right-handed female, normal orientation, normal recollection to 3 objects. the patient has underlying mr. speech, no aphasia, no dysarthria. cranial nerves, funduscopic intact without papilledema. pupils are equal, round, and reactive to light. extraocular movements intact. no nystagmus. her mood is intact. symmetric face sensation. symmetric smile and forehead. intact hearing. symmetric palate elevation. symmetric shoulder shrug and tongue midline. motor 5/5 proximal and distal. the patient does have limp on the right lower extremity. her babinski is hyperactive on the left lower extremity, upgoing toes on the left. sensory, the patient does have sharp, soft touch, vibration intact and symmetric. the patient has trouble with ambulation. she does have ataxia and uses a walker to ambulate. there is no bradykinesia. romberg is positive to the left. cerebellar, finger-nose-finger is intact. rapid alternating movements are intact. upper airway examination, the patient has a friedman tongue position with 4 oropharyngeal crowding. neck more than 16 to 17 inches, bmi elevated above 33. head and neck circumference very high.,impression:,1. cerebral palsy, worsening seizures.,2. hypertension.,3. dyslipidemia.,4. obstructive sleep apnea.,5. obesity.,recommendations:,1. admission to the emu, drop her carbatrol 200 b.i.d., monitor for any epileptiform activity. initial time of admission is 3 nights and 3 days.,2. outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated. continue her other medications.,3. consult dr. x for hypertension, internal medicine management.,4. i will follow this patient per emu protocol.

history of present illness:, the patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when i first saw him in the office on 01/11/06. he is now 77 years old. he is being seen on the seventh floor. the patient is in room 7607. the patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. the workup began with gi bleeding. he was seen in my office on 01/11/06 for preop evaluation due to leg edema. a nonocclusive dvt was diagnosed in the proximal left superficial femoral vein. both legs were edematous, and bilateral venous insufficiency was also present. an echocardiogram demonstrated an ejection fraction of 50%. the patient was admitted to the hospital and treated with a greenfield filter since anticoagulant was contraindicated. additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. the rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. there was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. the ejection fraction was considered low normal, since it was estimated 50 to 54%. the patient received blood while in the hospital due to anemia. the leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. the patient, who was diabetic, received consultation by dr. r. he was also a chronic hypertensive and was treated for that with ace inhibitors. the atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. as a matter of fact, they were discontinued. now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,allergies:, the patient has no known drug allergies.,his diabetes was suspected to be complicated with neuropathy due to tingling in both feet. he received his immunizations with flu in 2005 but did not receive pneumovax.,social history:, the patient is married. he had 1 child who died at the age of 26 months of unknown etiology. he quit smoking 6 years ago but dips (smokeless) tobacco.,family history:, mother had cancer, died at 70. father died of unknown cause, and brother died of unknown cause.,functional capacity:, the patient is wheelchair bound at the time of his initial hospitalization. he is currently walking in the corridor with assistance. nocturia twice to 3 times per night.,review of systems:,ophthalmologic: uses glasses.,ent: complains of occasional sinusitis.,cardiovascular: hypertension and atrial fibrillation.,respiratory: normal.,gi: colon bleeding. the patient believes he had ulcers.,genitourinary: normal.,musculoskeletal: complains of arthritis and gout.,integumentary: edema of ankles and joints.,neurological: tingling as per above. denies any psychiatric problems.,endocrine: diabetes, niddm.,hematologic and lymphatic: the patient does not use any aspirin or anticoagulants and is not of anemia.,laboratory:, current ekg demonstrates atrial fibrillation with incomplete left bundle branch block pattern. q waves are noticed in the inferior leads. nonprogression of the r-wave from v1 to v4 with small r-waves in v5 and v6 are suggestive of an old anterior and inferior infarcts. left ventilator hypertrophy and strain is suspected.,physical examination:,general: on exam, the patient is alert, oriented and cooperative. he is mildly pale. he is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,vital signs: blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. pulse oximetry is 100.,neck: without jvd, bruit, or thyromegaly. the neck is supple.,chest: symmetric. there is no heave or retraction.,heart: the heart sounds are irregular and no significant murmurs could be auscultated.,lungs: clear to auscultation.,abdomen: exam was deferred.,legs: without edema. pulses: dorsalis pedis pulse was palpated bilaterally.,medications:, current medications include enalapril, low dose enoxaparin, fentanyl patches. he is no longer on fluconazole. he is on a sliding scale as per dr. holden. he is on lansoprazole (prevacid), toradol, piperacillin/tazobactam, hydralazine p.r.n., zofran, dilaudid, benadryl, and lopressor p.r.n.,assessment and plan:, the patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. his cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. he has chronic atrial fibrillation. i do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. he is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. reason being is high likelihood for gi bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. at this point, i agree with the notion of hospice care. if his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, i would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.

preoperative diagnoses:,1. xxx upper lid laceration.,2. xxx upper lid canalicular laceration.,postoperative diagnoses:,1. xxx upper lid laceration.,2. xxx upper lid canalicular laceration.,procedures:,1. repair of xxx upper lid laceration.,2. repair of xxx upper lid canalicular laceration.,anesthesia:, general,specimens:, none.,complications:, none.,indications:, this is a xx-year-old (wo)man with xxx eye upper eyelid laceration involving the canaliculus.,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 was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. the patient then had the wound freshened up with westcott scissors and cotton-tip applications. hemostasis was achieved with a high-temp disposable cautery. once this had been done, the proximal end of the xxx upper lid canalicular system was intubated with a monoka tube on a prolene. the proximal end was then found and this was intubated with the same tubing system. then, two 6-0 vicryl sutures were used to reapproximate the medial canthal tendon. once this had been done, the skin was reapproximated with interrupted 6-0 vicryl sutures and interrupted 6-0 plain gut sutures. to ensure that the punctum was in the correct position and in the monoka tube was seated with a seater, and the tube was cut short. the patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (s)he left the operating room in good condition.

subjective:, this 47-year-old white female presents with concern about possible spider bite to the left side of her neck. she is not aware of any specific injury. she noticed a little tenderness and redness on her left posterior shoulder about two days ago. it seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck. she has had no fever. the area is very minimally tender, but not particularly so.,current medications:, generic maxzide, climara patch, multivitamin, tums, claritin, and vitamin c.,allergies:, no known medicine allergies.,objective:,vital signs: weight is 150 pounds. blood pressure 122/82.,extremities: examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter. in the center is a tiny mark which could certainly be an insect or spider bite. there is no eschar there, but just a tiny marking. there are a couple of erythematous streaks extending towards the neck.,assessment:, possible insect bite with lymphangitis.,plan:,1. duricef 1 g daily for seven days.,2. cold packs to the area.,3. discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4. incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas. i suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.

procedure:, upper endoscopy with removal of food impaction.,history of present illness: , a 92-year-old lady with history of dysphagia on and off for two years. she comes in this morning with complaints of inability to swallow anything including her saliva. this started almost a day earlier. she was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything. she is on coumadin and her inr is 2.5.,operative note: , informed consent was obtained from patient. the risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and icu stay particularly in view of food impaction for almost a day was discussed. daughter was also informed about the procedure and risks. conscious sedation initially was administered with versed 2 mg and fentanyl 50 mcg. the scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus. there was a meat bolus in the distal esophagus. this was visualized after clearing the liquid material and small particles of what appeared to be carrots. the patient, however, was not tolerating the conscious sedation. hence, dr. x was consulted and we continued the procedure with propofol sedation.,the scope was reintroduced into the esophagus after propofol sedation. initially a roth net was used and some small amounts of soft food in the distal esophagus was removed with the roth net. then, a snare was used to cut the meat bolus into pieces, as it was very soft. small pieces were grabbed with the snare and pulled out. thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully. the patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and coumadin therapy. no active bleeding was seen. there was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach. as this area was extremely inflamed, a dilatation was not attempted.,impression: , distal esophageal stricture with food impaction. treated as described above.,recommendations:, iv protonix 40 mg q.12h. clear liquid diet for 24 hours. if the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks. she should take prevacid solutab 30 mg b.i.d. on discharge.

identifying data: ,the patient is a 40-year-old white male. he is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,chief complaint and reaction to hospitalization: ,the patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at hospital emergency room, the morning prior to admission.,history of present illness: ,the patient was very sleepy this morning, only minimally cooperative with interview. additional information taken from the emergency room records that accompanied him from hospital yesterday as well as from his wife, who i contacted by telephone. the patient was apparently at his stable baseline when discharged from the hospital on 01/21/10, status post back surgery following a work-related injury. the patient returned to emergency room on the evening prior to admission complaining of severe back pain. his er course is notable for yelling, spitting, and striking multiple staff members. the patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to mhps, who subsequently detained him for 72 hours for dangerousness to others. on interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. he was contrite about the violence. when his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,his wife reports that after discharge from the hospital, on 01/21/10, he was prescribed percocet, soma, hydroxyzine, and valium. he essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. she reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." she denies feeling that he currently represents a threat to her or her five children. she was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,past psychiatric history: , the patient has a history of involuntary treatment act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. the patient denies any outpatient mental health treatment before or since this hospitalization. he describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,past medical history:, notable for status post back surgery, discharged from hospital on 01/21/10.,medications:, from discharge from hospital on 01/21/10, include percocet, valium, soma, and vistaril, doses and frequency are not currently known. his wife reports that he was discharged with approximately 10 days' supply of these agents.,social and developmental history: ,the patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. he lives with his wife and children. he has a history of domestic violence, but not recently. other details of occupational, educational history not currently known.,substance and alcohol history:, records indicate a previous history of methamphetamine and alcohol abuse/dependence. the wife states that he has not consumed either since 12/07. of note, urine tox screen at hospital was positive for marijuana.,legal history: ,the patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. it is not known whether the patient is currently on probation.,genetic psychiatric history: , unknown.,mental status examination:,attitude: the patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,appearance: he is unkempt and there are multiple visible tattoos on his biceps.,psychomotor: there is no obvious psychomotor agitation or retardation. there are no obvious extrapyramidal symptoms of tardive dyskinesia.,affect: his affect is notably restricted probably due to the fact that he is sleepy.,mood: describes his mood as "okay.",speech: speech is normal rate, volume, and tone.,thought processes: his thought processes appear to be linear.,thought content: his thought content is notable for his expressions of contrition about violence at hospital last night. he denies suicidal or homicidal ideation.,cognitive assessment: cognitively, he is alert and oriented to person, place, and date but not situation. attributes this to not really remembering the events at hospital that resulted in this hospitalization.,judgment and insight: his insight and judgment are both appear to be improving.,assets: include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,limitations: include his back injury and possible need for improvement of health treatment engagement.,formulation: ,this is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, soma, hydroxyzine, and valium. he appears much improved from his condition at hospital last night and i suspect that his behavior is most likely attributed to delirium and this since resolved. he reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,diagnoses:,axis i: delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, soma, valium, and hydroxyzine.) rule out bipolar affective disorder.,axis ii: deferred.,axis iii: chronic pain status post back surgery.,axis iv: appears to be moderate. he is currently on medical leave from his job.,axis v: global assessment of functioning is currently 50 (his gaf was 20 approximately 24 hours ago).,estimated length of stay:, three days.,plan:, i will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, i suspect is likely due to misuse of prescribed medications. the patient will be placed on ciwa protocol given that one of the medications he overused was valium. of note, he does not currently appear to be withdrawing and i anticipate that his ciwa will be discontinued prior to discharge. i would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. the internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.

preoperative diagnoses:,1. displaced intraarticular fracture, right distal radius.,2. right carpal tunnel syndrome.,preoperative diagnoses:,1. displaced intraarticular fracture, right distal radius.,2. right carpal tunnel syndrome.,operations performed:,1. open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2. right carpal tunnel release.,anesthesia: , general.,clinical summary: , the patient is a 37-year-old right-hand dominant hispanic female who sustained a severe fracture to the right wrist approximately one week ago. this was an intraarticular four-part fracture that was displaced dorsally. in addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop. she is admitted for reconstructive operation. the symptoms of carpal tunnel were present preop and worsened after the injury.,operation:, the patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by anesthesia. once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner. tourniquet was placed around the right upper extremity. the upper extremity was then elevated and exsanguinated using an esmarch dressing. the tourniquet was elevated to 250 mmhg. the entire operation was performed with 4.5 loop magnification. at this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally. this was carried down to the flexor carpi radialis, which was then retracted ulnarly. the floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles. the flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin. it was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced. this was an intraarticular four-part fracture. under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced. then, 2.06 two-inch k-wires were drilled radial into the volar ulnar fragment and then a second k-wire was then drilled from the dorsal radial to the dorsal ulnar piece. a third k-wire was then drilled from the volar radial to the dorsal ulnar piece. the fracture was then manipulated. the fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it. further k-wires were then placed through the radial styloid into the proximal fragment. a hand innovations dvr plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two k-wires. at this time, the distal screws were then placed. the distal screws were the small screws. these were non-locking screws, all eight screws were placed. they were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth. again, these were 18-20 mm screws. after placing three of the screws it was necessary to remove the k-wires. there was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture. after the distal screws were placed, the fracture was reduced and held in place with k-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit. the screws were then placed. these were 12 mm screws. they were placed 4 in number. the k-wires were then removed. finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist. this was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure. it was dissected free from the structure out to its trifurcation. the motor branches seen entering the thenar fascia and obstructed. the nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm. in this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon. incisions were then copiously irrigated with normal saline. homeostasis was maintained with electrocautery. the pronator quadratus was closed with 3-0 vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion. a large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position. the tourniquet was let down. the fingers were immediately pink. the patient was awakened and taken to the recovery room in good condition. there were no operative complications. the patient tolerated the procedure well.

preoperative diagnoses:,1. left carpal tunnel syndrome (354.0).,2. left ulnar nerve entrapment at the elbow (354.2).,postoperative diagnoses:,1. left carpal tunnel syndrome (354.0).,2. left ulnar nerve entrapment at the elbow (354.2).,operations performed:,1. left carpal tunnel release (64721).,2. left ulnar nerve anterior submuscular transposition at the elbow (64718).,3. lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,anesthesia: , general anesthesia with intubation.,indications of procedure: , this patient is insulin-dependant diabetic. he is also has end-stage renal failure and has chronic hemodialysis. additionally, the patient has had prior heart transplantation. he has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity. however, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger. these started initially as unrecognized paper cuts. additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger. finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger. thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary. thirdly, this patient does have chronic distal ischemic problems with evidence of "ping-pong ball sign" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers. however, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,the patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks. thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve. this patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,description of procedure: , after general anesthesia being induced and the patient intubated, he is given intravenous ancef. the entire left upper extremity is prepped with betadine all the way to the axilla and draped in a sterile fashion. a sterile tourniquet and webril are placed higher on the arm. the arm is then exsanguinated with ace bandage and tourniquet inflated to 250 mmhg. i started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease. dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal. i next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm. having confirmed a complete release of the transverse carpal ligament, i next evaluated the contents of the carpal tunnel. the synovium was somewhat thickened, but not unduly so. there was some erythema along the length of the median nerve, indicating chronic compression. the motor branch of the median nerve was clearly identified. the contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified. the wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,i next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle. dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass. in the process of elevating this skin flap i elevated and deactivated shunt together with the skin flap. i now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until i identified the median nerve.,i turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and i dissected it all the way proximally until i encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm. the entire medial intramuscular septum is now excised. the ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures. larger penetrating vascular tributaries to the muscle ligated between hemoclips. i continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the fcu muscle fibers. the nerve is now mobilized and i had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques. in this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,i now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner. because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other. so that in effect a lengthening is performed. fascial repair is done with interrupted figure-of-eight 0-ethibond sutures. i now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve. the entire arm is next wrapped with a kerlix wrap and i released the tourniquet and after allowing the reactive hyperemia to subside, i then unwrap the arm and check for hemostasis. wound is copiously irrigated with normal saline and then a 15-french round blake drainage placed through a separate stab incision and laid along the length of the wound. a layered wound closure is done with interrupted vicryl subcutaneously, and a running subcuticular monocryl to the skin. a 0.25% plain marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of adaptic impregnated bacitracin ointment, followed by a well-fluffed gauze and a kerlix dressing and confirming kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist. fingers and femoral were free to move. the splint is well padded with webril and is in turn held in place with kerlix and ace bandage. meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition. sponge and needle counts reported as correct at the end of the procedure.

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

procedure: , lumbar puncture with moderate sedation.,indication: , the patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct coombs test. she was transfused with packed red blood cells. her hemolysis seemed to slow down. she also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen. culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital. she had a blood culture, which was also negative. she was empirically started on presentation with the cefotaxime intravenously. her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics. after antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present. she also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her uti.,i discussed with the patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures. the risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression. questions were answered to their satisfaction. they would like to proceed.,procedure in detail: , after "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained. she was then given versed 1 mg intravenously by myself. she subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied. she was then given 20 mcg of fentanyl intravenously by myself. she was placed in the left lateral decubitus position. dr. x cleansed the patient's back in a normal sterile fashion with betadine solution. she inserted a 22-gauge x 1.5-inch spinal needle in the patient's l3-l4 interspace that was carefully identified under my direct supervision. clear fluid was not obtained initially, needle was withdrawn intact. the patient was slightly repositioned by the nurse and dr. x reinserted the needle in the l3-l4 interspace position, the needle was able to obtain clear fluid, approximately 3 ml was obtained. the stylette was replaced and the needle was withdrawn intact and bandage was applied. betadine solution was cleansed from the patient's back.,during the procedure, there were no untoward complications, the end-tidal co2, pulse oximetry, and other vitals remained stable. of note, emla cream had also been applied prior procedure, this was removed prior to cleansing of the back.,fluid will be sent for a routine cell count, gram stain culture, protein, and glucose.,disposition: , the child returned to room on the medical floor in satisfactory condition.

title of operation:, lateral and plantar condylectomy, fifth left metatarsal.,preoperative diagnosis: , prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,postoperative diagnosis: , prominent, lateral, and plantar condyle hypertrophy, fifth left metatarsal.,anesthesia: ,monitored anesthesia care with 10 ml of 1:1 mixture of both 0.5% marcaine and 1% lidocaine plain.,hemostasis:, 30 minutes, left ankle tourniquet set at 250 mmhg.,estimated blood loss: , less than 10 ml.,materials used: , 3-0 vicryl and 4-0 vicryl.,injectables:, ancef 1 g iv 30 minutes preoperatively.,description of the procedure: , the patient was brought to the operating room and placed on the operating table in a supine position. after adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites. the left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmhg. the left foot was then prepped, scrubbed, and draped in a normal sterile technique. the left ankle tourniquet was inflated. attention was then directed on the dorsolateral aspect of the fifth left metatarsophalangeal joint where a 4-cm linear incision was placed over the fifth left metatarsophalangeal joint parallel and lateral to the course of the extensor digitorum longus to the fifth left toe. the incision was deepened through the subcutaneous tissues. all the bleeders were identified, cut, clamped, and cauterized. the incision was deepened to the level of the capsule and the periosteum of the fifth left metatarsophalangeal joint. all the tendinous and neurovascular structures were identified and retracted from the site to be preserved. using sharp and dull dissection, the soft tissue attachments through the fifth left metatarsal head were mobilized. the lateral and plantar aspect of the fifth left metatarsal head were adequately exposed and using the sagittal saw a lateral and plantar condylectomy of the fifth left metatarsal head were then achieved. the bony prominences were removed and passed off the operating table to be sent to pathology for identification. the remaining sharp edges of the fifth left metatarsal head were then smoothened with the use of a dental rasp. the area was copiously flushed with saline. then, 3-0 vicryl and 4-0 vicryl suture materials were used to approximate the periosteal, capsular, and subcutaneous tissues respectively. the incision was reinforced with steri-strips. range of motion of the fifth left metatarsophalangeal joint was tested and was found to be excellent and uninhibited. the patient's left ankle tourniquet at this time was deflated. immediate hyperemia was noted to the entire left lower extremity upon deflation of the cuff. the patient's incision was covered with xeroform, copious amounts of fluff and kling, stockinette, and ace bandage and the patient's left foot was placed in a surgical shoe. the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels. the patient was given pain medications and instructions on how to control her postoperative course. she was discharged from hospital according to nursing protocol and was will follow up with dr. x in one week's time for her first postoperative appointment.

preoperative diagnoses: , nasal fracture and deviated nasal septum with obstruction.,postoperative diagnoses: , nasal fracture and deviated nasal septum with obstruction.,operation:, open reduction, nasal fracture with nasal septoplasty.,anesthesia: , general.,history: , this 16-year-old male fractured his nose playing basketball. he has a left nasal obstruction and depressed left nasal bone.,description of procedure: , the patient was given general endotracheal anesthesia and monitored with pulse oximetry, ekg, and co2 monitors.,the face was prepped with betadine soap and solution and draped in a sterile fashion. nasal mucosa was decongested using afrin pledgets as well as 1% xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.,inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. further up, the cartilaginous septum was displaced to the left of the maxillary crest. there was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.,there was a large deep groove horizontally on the right side corresponding to the left maxillary crest.,a left hemitransfixion incision was made. mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.,the caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. the right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.,the caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.,further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.,further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with jansen-middleton punch forceps.,the main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.,this area was freed from the perichondrium on both sides. the maxillary crest was removed with a gouge. vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.,thus, the deviated septum was corrected. left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. the septum was also filtered with #4-0 plain catgut sutures.,by valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.,next, the nasal bone suture deviated to the left side were corrected. the right nasal bone was depressed and left nasal bone was wide. therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. the left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.,steri-strips were applied to the nasal dorsal skin and a denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.,nasal cavities were packed with telfa gauze rolled on both sides with bacitracin ointment. approximate blood loss was 10 to 20 ml.

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.

coccygeal injection,procedure:,: informed consent was obtained from the patient. a gloved little finger was inserted into the anal region and the sacral/coccygeal joint was palpated and the coccyx was moved and it was confirmed that this reproduced pain. after aseptic cleaning, a 25-gauge needle was inserted through the skin into the sacral/coccygeal joint. it was confirmed that the needle was not entering the rectal cavity by finger placed in the rectum. after aspiration, 1 ml of cortisone and 2 ml of 0.25% marcaine were injected at the site. postprocedure, the needle was withdrawn. a small pressure dressing was placed and no hematoma was observed to form.,post procedure instructions:, the patient has been asked to report to us any redness, swelling, inflammation, or fevers. the patient has been asked to restrict the use of the * extremity for the next 24 hours.

reason for referral: ,the patient was referred for a neuropsychological evaluation by dr. x. a comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,brief summary & impressions:,relevant history:,historical information was obtained from a review of available medical records and an interview with ,the patient.,the patient presented to dr. x on august 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope. she was referred to dr. x for diagnostic differentiation for possible seizures or other causes of syncope. the patient reports an extensive neurological history. her mother used alcohol during her pregnancy with the patient. in spite of exposure to alcohol in utero, the patient reported that she achieved "honors in school" and "looked smart." she reported that she began to experience migraines at 11 years of age. at 15 years of age, she reported that she was thought to have hydrocephalus. she reported that she will frequently "bang her head against the wall" to relieve the pain. the patient gave birth to her daughter at 17 years of age. at 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches. she reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and "thrown two and a half city blocks." the patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day. she reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month. her migraines became more severe following the head injury. in 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights. following the syncope episode, she would experience some confusion. these episodes reportedly were related to her donating plasma.,the patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep. she reported that upon awakening, she would feel off balanced and somewhat confused. these episodes diminished from 2002 to june 2008. when making dinner, she suddenly dropped and hit the back of her head on refrigerator. she reported that she was unconscious for five to six minutes. a second episode occurred on july 20th when she lost consciousness for may be a full day. she was admitted to sinai hospital and assessed by a neurologist. her eeg and head ct were considered to be completely normal. she did not report any typical episodes during the time of her 36-hour eeg. she reported that her last episode of syncope occurred prior to her being hospitalized. she stated that she had an aura of her ears ringing, vision being darker and "tunnel vision" (vision goes smaller to a pinpoint), and she was "spazzing out" on the floor. during these episodes, she reports that she cannot talk and has difficulty understanding.,the patient also reports that she has experienced some insomnia since she was 6 years old. she reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of jack daniel. she stopped the use of alcohol and that time she experienced a suicide attempt. in 2002, she was diagnosed with bipolar disorder and was started on medication. at the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself. the patient's medical history is also significant for postpartum depression.,the patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory. she reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes. she finds that she often has difficulty with expressing her thoughts, as she is very tangential. she experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform. she reported that she had a photographic memory for directions. she said that she experienced a great deal of emotional lability, but in general her personality has become more subdued. at the present time, her daughter has now moved on to college. the patient is living with her biological mother. although she is going through divorce, she reported that it was not really stressful. she reported that she spends her day driving other people around and trying to be helpful to them.,at the time of the neuropsychological evaluation, the patient's medication included ativan, imitrex, levoxyl, vitamin b12, albuterol metered dose inhaler as needed, and zofran as needed. (it should be noted that the patient by the time of the feedback on september 19, 2008 had resumed taking her trileptal for bipolar disorder.). the patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,tests administered:,clinical interview,cognistat,mattis dementia rating scale,wechsler adult intelligence scale - iii (wais-iii),wechsler abbreviated scale of intelligence (wasi),selected subtests from the delis kaplan executive function system (dkefs), trail making test, verbal fluency (letter fluency & category fluency), design fluency, color-word interference test, tower,wisconsin card sorting test (wcst),stroop test,color trails,trails a & b,test of variables of attention,multilingual aphasia examination ii, token test, sentence repetition, visual naming, controlled oral word association, spelling test, aural comprehension, reading comprehension,boston naming test-2 (bnt-2),animal naming test,the beery-buktenica developmental test of visual-motor integration (vmi),the beery-buktenica developmental test of motor coordination,the beery-buktenica developmental test of visual perception,judgment line orientation,grooved pegboard,purdue pegboard,finger tapping test,rey complex figure,wechsler memory scale -iii (wms-iii),california verbal learning test

general:, negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,integumentary: , negative rash, negative jaundice.,hematopoietic: , negative bleeding, negative lymph node enlargement, negative bruisability.,neurologic: , negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. no history of strokes, no history of other neurologic conditions.,eyes:, negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,ears: , negative tinnitus, negative vertigo, negative hearing impairment.,nose and throat: ,negative postnasal drip, negative sore throat.,cardiovascular: , negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. no history of heart attack, no history of arrhythmias, no history of hypertension.,respiratory:, no history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,gastrointestinal: , negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,genitourinary: , negative frequency, negative urgency, negative dysuria, negative incontinence. no history of stds.,musculoskeletal:, negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,psychiatric: , see psychiatric evaluation.,endocrine: , no history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.

exam:, noncontrast ct scan of the lumbar spine,reason for exam: , left lower extremity muscle spasm.,comparisons: , none.,findings: , transaxial thin slice ct images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,no abnormal paraspinal masses are identified.,there are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,there is marked intervertebral disk space narrowing at the l5-s1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes. posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left. this most likely will affect the s1 nerve root on the left. there are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly. there is mild neural foraminal stenosis present. small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root. there is facet sclerosis bilaterally. mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,at the l4-5 level, mild bilateral facet arthrosis is present. there is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally. no moderate or high-grade central canal or neural foraminal stenosis is identified.,at the l3-4 level anterior spondylosis is present. there are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,at the l2-3 level, there is mild bilateral ligamentum flavum hypertrophy. mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,at the t12-l1 and l1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,there is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation. no bony destructive changes or acute fractures are identified.,conclusions:,1. advanced degenerative disk disease at the l5-s1 level.,2. probable chronic asymmetric herniated disk protrusion with peripheral calcification at the l5-s1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. mild bilateral neural foraminal stenosis at the l5-s1 level.,4. posterior disk bulging at the l2-3, l3-4, and l4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. facet arthrosis to the lower lumbar spine.,6. arteriosclerotic vascular disease.

preoperative diagnosis: , tonsillitis.,postoperative diagnosis: ,tonsillitis.,procedure performed: ,tonsillectomy.,anesthesia: , general endotracheal.,description of procedure: ,the patient was taken to the operating room and prepped and draped in the usual fashion. after induction of general endotracheal anesthesia, the mcivor mouth gag was placed in the oral cavity and a tongue depressor applied. two #12-french red rubber robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction. the nasopharynx was inspected with the laryngeal mirror.,attention was then directed to the right tonsil. the anterior tonsillar pillar was infiltrated with 1.5 cc of 1% xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar. the right tonsil was grasped with the tenaculum and retracted out of its fossa. the anterior tonsillar pillar was incised with the #12 knife blade. the plica semilunaris was incised with the metzenbaum scissors. using the metzenbaum scissors and the fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied. the tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described. by a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,attention was re-directed to the right tonsil. the pack was removed and bleeding was controlled with the suction bovie unit. bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs. the catheters were then removed. the nasal passages and oropharynx were suctioned free of debris. the procedure was terminated.,the patient tolerated the procedure well and left the operating room in good condition.

indications:, previously markedly abnormal dobutamine myoview stress test and gated scan.,procedure done:, resting myoview perfusion scan and gated myocardial scan.,myocardial perfusion imaging:, resting myocardial perfusion spect imaging and gated scan were carried out with 32.6 mci of tc-99m myoview. rest study was done and compared to previous dobutamine myoview stress test done on month dd, yyyy. the lung heart ratio is 0.34. there appears to be a moderate size inferoapical perfusion defect of moderate degree. the gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,conclusions:, study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree. the left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on month dd, yyyy. we cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.

exam: , ct chest with contrast.,history: , abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,technique: ,post contrast-enhanced spiral images were obtained through the chest.,findings: ,there are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates. the remainder of the lung parenchyma is clear. there is no pneumothorax or effusion. the heart size and pulmonary vessels appear unremarkable. there was no axillary, hilar or mediastinal lymphadenopathy.,images of the upper abdomen are unremarkable.,osseous windows are without acute pathology.,impression: , several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.

preoperative diagnosis: ,cervical spondylosis and herniated nucleus pulposus of c4-c5.,postoperative diagnosis:, cervical spondylosis and herniated nucleus pulposus of c4-c5.,title of operation:, anterior cervical discectomy c4-c5 arthrodesis with 8 mm lordotic acf spacer, corticocancellous, and stabilization with synthes vector plate and screws.,estimated blood loss:, less than 100 ml.,operative procedure in detail: , after identification, the patient was taken to the operating room and placed in supine position. following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. a shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position. a preoperative x-ray was obtained to identify the operative level and neck position. an incision was marked at the c4-c5 level on the right side. the incision was opened with #10 blade knife. dissection was carried down through subcutaneous tissues using bovie electrocautery. the platysma muscle was divided with the cautery and mobilized rostrally and caudally. the anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection. the avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia. this was opened with scissors and dissected rostrally and caudally with the peanut dissectors. the operative level was confirmed with an intraoperative x-ray. the longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator. the anterior longitudinal ligament was then taken down with the insulated bovie electrocautery tip exposing the vertebral bodies of c4 and c5. self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of c4 and c5, and distraction was instituted. we then incise the annulus of c4-c5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes. operating microscope was draped and brought into play. dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went. we now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally. bone was then removed with 2 mm kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm kerrison punch. there was a transligamentous disc herniation, which was removed during this process. we then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent. cord was seen to be pulsating freely behind the dura. there appeared to be no complications and the decompression appeared adequate. we now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the c5 vertebral body. an 8 mm lordotic trial was used and appeared perfect. we then used a corticocancellous 8 mm lordotic graft. this was tapped into position. distraction was released, appeared to be in excellent position. we then positioned an 18 mm vector plate over the inner space. intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position. we then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion. all of the screws locked to the plate and this was confirmed on visual inspection. intraoperative x-ray was again obtained. construct appeared satisfactory. attention was then directed to closure. the wound was copiously irrigated. all of the self-retaining retractors were removed. bleeding points were controlled with bone wax and bipolar electrocautery. the platysma layer was now closed with interrupted 3-0 vicryl sutures. the skin was closed with running 3-0 vicryl subcuticular stitch. steri-strips were applied. a sterile bandage was applied. all sponge, needle, and cottonoid counts were reported as correct. the patient tolerated the procedure well. he was subsequently extubated in the operating room and transferred to pacu in satisfactory condition.

chief complaint:, abdominal pain, nausea and vomiting.,history of present illness:, a 50-year-old asian female comes to the methodist hospital on january 2, 2001, complaining of a 3-day history of abdominal pain. the pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. the patient denied passing any stool or gas per rectum for the previous 24 hours. she had been admitted recently to the hospital from december 19 to december 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin "lumps". she described a total of three "lumps". the first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. they were described as "erythematous nodular lesions on the extensor surface of the left arm." a punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained "multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis". however, one granuloma in the deep dermis, showed a hint of central necrosis. special stains for acid - fast bacilli and fungi were reported as negative. no atypia or malignancy was noted. a ct scan of the chest was obtained on december 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. no cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. the patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. they were also able to appreciate intra-alveolar fibrinous exudates. one of the blood cultures drawn on december 19, 2000 grew streptococcus mitis.,the patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.,past medical history:,1. post-streptococcal glomerulonephritis at age 10.,2. end stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.,3. cadaveric transplant in october 1996,4. steroid induced diabetes mellitus,5. hypertension,past surgical history:,1. total abdominal hysterectomy in january 1996,2. cesarean section x2 in 1996 and 1997,3. appendectomy in 1971,4. insertion of peritoneal dialysis catheter in 1994,5. cadaveric transplant in october 1996,social history:,the patient denies a history of smoking, drinking or intravenous drug use. she came to the united states in 1973. she works as a nurse in a newborn nursery. her hobby is gardening. she traveled to las vegas on may 2000 and stayed for 6 months. she denied ill contacts or pets.,allergies:, ciprofloxacin and enteric coated aspirin,medications:, prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch tts 3 1/week, prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.,family history:, she described a family history of hypertension. her mother died after a myocardial infarction at age 59. her father was diagnosed with congestive heart failure and had a pacemaker placed.,review of systems:, non-contributory. the patient denied fever, chills, ulcers, liver disease or history of gallstones.,vaccines: the patient was vaccinated with bcg before starting elementary school in the philippines.,physical examination:, at the time of the examination the patient was alert and oriented times three and in no acute distress. she was well nourished.,bp 106/60 lying down; hr 86; rr 12; t 96.1° f; hgt. =5' 2"; wgt. =121 lbs.,skin: there was no rash or skin lesions.,heent: she had no oral lesions and moist mucous membranes. no icterus was noted.,neck: her neck was supple without lymphadenopathy or thyromegaly.,lungs: crackles at the right lower base with normal respiratory excursion and no dullness to percussion.,heart: iv/vi crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck.,abdomen: the abdomen was distended. bowel sounds were normal. no hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination.,extremities: no cyanosis, clubbing or edema was noted.,rectal: normal rectal exam. guaiac negative.,neurologic: normal and non-focal.,hospital course:, the patient was admitted and a nasogastric tube was placed. iv fluids were started. a kub was obtained showing an abnormal bowel gas pattern. multiple loops of distended bowel were noted in the mid abdomen. air and feces were noted within the colon in the right side. an abdominal ct scan was obtained. there was a small amount of perihepatic fluid noted. the liver and spleen were normal. the kidneys were atrophic. the gallbladder was moderately distended. there was marked dilatation of the small bowel proximally and distally. there was gas and contrast material in the colon. a diagnostic procedure was performed.

reason for visit: ,followup cervical spinal stenosis.,history of present illness: ,ms. abc returns today for followup regarding her cervical spinal stenosis. i have last seen her on 06/19/07. her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,i referred her to obtain a cervical spine mri.,she returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. she had some physical therapy, which has been helping with the neck pain. the right hand weakness continues. she states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. she states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,she has been undergoing nonoperative management by dr. x and feels this has been helping her neck pain, but not the upper extremity symptoms.,she denies any bowel and bladder dysfunction. no lower back pain, no lower extremity pain, and no instability with ambulation.,review of systems:, negative for fevers, chills, chest pain, and shortness of breath.,findings: ,on examination, ms. abc is a very pleasant well-developed, well-nourished female in no apparent distress. alert and oriented x3. normocephalic and atraumatic. afebrile to touch.,she ambulates with a normal gait.,motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,light touch sensation decreased in the right greater than left c6 distribution. biceps and brachioradialis reflexes are 3 plus. hoffman sign normal bilaterally.,lower extremity strength is 5 out of 5 in all muscle groups. patellar reflex is 3 plus. no clonus.,cervical spine radiographs dated 06/21/07 are reviewed.,they demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at c4-5, c5-6, c6-7, and c3-4 demonstrates only minimal if any degenerative disk disease. there is no significant instability seen on flexion-extension views.,updated cervical spine mri dated 06/21/07 is reviewed.,it demonstrates evidence of moderate stenosis at c4-5, c5-6. these stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the c6-7 level. minimal degenerative disk disease is seen at the c6-7. this stenosis is greater than c5-6 and the next level is more significantly involved at c4-5.,effacement of the ventral and dorsal csf space is seen at c4-5, c5-6.,assessment and plan: , ms. abc's history, physical examination, and radiographic findings are compatible with c4-5, c5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,i spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,i laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,the patient states she would like to avoid injections and is somewhat afraid of having these done. i explained to her that they may help to improve her symptoms, although they may not help with the weakness.,she feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,i described the procedure consisting of c4-5, c5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,i explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain. she understands.,i discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age. of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,i also discussed the option of disk arthroplasty. she understands.,she would like to proceed with the surgery, relatively soon. she has her birthday coming up on 07/20/07 and would like to hold off, until after then. our tentative date for the surgery is 08/01/07. she will go ahead and continue the preoperative testing process.

principal diagnoses:,1. a 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with beam regimen in 04/02 followed by relapse.,2. allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3. graft versus host disease involving gi tracts, skin, and liver presently off immunosuppression.,4. diabetes.,5. bipolar disorder.,6. chronic muscle aches.,7. chronic lower extremity edema.,8. ecog performance status 1.,interim history: , the patient comes to the clinic today for followup. i am seeing him once every 4 to 8 weeks. he is off of all immunosuppression. he does have mild chronic gvhd but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,he has multiple complaints. he has had hematochezia. i referred him to gastroenterology. they did an upper and lower endoscopy. no evidence of ulcers or any abnormality was found. some polyps were removed. they were benign. he may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,current medications:,1. paxil 40 mg once daily.,2. cozaar.,3. xanax 1 mg four times a day.,4. prozac 20 mg a day.,5. lasix 40 mg a day.,6. potassium 10 meq a day.,7. mirapex two tablets every night.,8. allegra 60 mg twice a day.,9. avandamet 4/1000 mg daily.,10. nexium 20 mg a day.,11. novolog 25/50.,review of systems:, fatigue, occasional rectal bleeding, and obesity. other systems were reviewed and were found to be unremarkable.,physical examination:,vital signs: today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. heent: oral cavity, no mucositis. neck: no nodes. axilla: no nodes. lungs: clear. cardiac: regular rate and rhythm without murmurs. abdomen: no palpable masses. morbid obesity. extremities: mild lower extremity edema. skin: mild dryness. cns: grossly intact.,laboratory data:, white count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, bun 15, and creatinine 0.9. normal alkaline phosphatase 203, ast 58, and alt 31.,assessment and plan:,1. the patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. he is without evidence of disease at the present time. since he is 4-1/2 years posttransplant, i do not plan to scan him or obtain chimerisms unless there is reason to.,2. he is slightly anemic, may be iron deficient. he has had recurrent rectal bleeding. i told him to take multivitamin with iron and see how that helps the anemia.,3. regarding the hematochezia, he had an endoscopy. i reviewed the results from the previous endoscopy. it appears that he has polyps, but there is no evidence of graft versus host disease.,4. regarding the fatigue, i just reassured him that he should increase his activity level, but i am not sure how realistic that is going to be.,5. he is followed for his diabetes by his internist.,6. if he should have any fever or anything suggestive of infection, i advised him to call me. i will see him back in about 2 months from now.

history of present illness: , the patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and i was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. when she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on cardizem with reportedly heart rate in the 50s, so that was stopped. review of ekgs from that time shows what appears to be multifocal atrial tachycardia with followup ekg showing wandering atrial pacemaker. an ecg this morning showing normal sinus rhythm with frequent apcs. her potassium at that time was 3.1. she does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. she denies any chest pain nor shortness of breath prior to or since the fall. she states clearly she can walk and she would be able to climb 2 flights of stairs without problems.,past cardiac history: , she is followed by dr. x in our office and has a history of severe tricuspid regurgitation with mild elevation and pa pressure. on 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. she has previously had a persantine myoview nuclear rest-stress test scan completed at abcd medical center in 07/06 that was negative. she has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. she has a history of hypertension and ekgs in our office show normal sinus rhythm with frequent apcs versus wandering atrial pacemaker. she does have a history of significant hypertension in the past. she has had dizzy spells and denies clearly any true syncope. she has had bradycardia in the past from beta-blocker therapy.,medications on admission:,1. multivitamin p.o. daily.,2. aspirin 325 mg once a day.,3. lisinopril 40 mg once a day.,4. felodipine 10 mg once a day.,5. klor-con 20 meq p.o. b.i.d.,6. omeprazole 20 mg p.o. daily presumably for gerd.,7. miralax 17 g p.o. daily.,8. lasix 20 mg p.o. daily.,allergies: , penicillin. it is listed that toprol has caused shortness of breath in her office chart and i believe she has had significant bradycardia with that in the past.,family history:, she states her brother died of an mi suddenly in his 50s.,social history: , she does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. she is retired from morse chain and delivering newspapers. she is widowed. she lives alone but has family members who live either on her property or adjacent to it.,review of systems: , she denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. she does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. she does note occasional peripheral edema. she is not aware of prior history of mi. she denies diabetes. she does have a history of gerd. she notes feeling depressed at times because of living alone. she denies rheumatologic conditions including psoriasis or lupus. remainder of review of systems is negative times 15 except as described above.,physical exam: ,height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, o2 saturation 97%. on general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. heent: shows cranium is normocephalic and atraumatic. she has moist mucosal membranes. neck veins were not distended. there are no carotid bruits. lungs: clear to auscultation anteriorly without wheezes. she is relatively immobile because of her left hip fracture. cardiac exam: s1, s2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. there is also a soft holosystolic murmur heard. there is no rub or gallop. pmi is nondisplaced. abdomen is soft and nondistended. bowel sounds present. extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. pulses appear grossly intact. affect is appropriate. visible skin warm and perfused. she is not able to move because of left hip fracture easily in bed.,diagnostic studies/lab data: , pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. no clear pulmonary vascular congestion. sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, bun 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. troponin was 0.03 followed by 0.18. inr is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.,ekgs are reviewed. initial ekg done on 08/19/08 at 1832 shows mat, heart rate of 104 beats per minute, no ischemic changes. she had a followup ekg done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral t-wave changes, not significantly changed from prior. followup ekg done this morning shows normal sinus rhythm with frequent apcs.,impression: ,she is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. telemetry now reviewed, shows predominantly normal sinus rhythm with frequent apcs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and i suspect that was exacerbated by prior hypokalemia, which has been corrected. there has been no atrial fibrillation documented. i do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. she actually describes feeling good exercise capacity prior to this fall. given favorable risk to benefit ratio for needed left hip surgery, i feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. continued optimization of electrolytes. the patient cannot take beta-blockers as previously toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. the patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. i do not feel any further cardiac evaluation is needed at this time and the patient may followup with dr. x after discharge. regarding her mild thrombocytopenia, i would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist.

chief complaint: , mgus.,history of present illness:, this is an extremely pleasant 86-year-old gentleman, who i follow for his mgus. i initially saw him for thrombocytopenia when his anc was 1300. a bone marrow biopsy was obtained. interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000. his bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia. all his tests came back as consistent with an mgus.,overall, he is doing well. since i last saw him, he tells me that he has had onset of atrial fibrillation. he has now started going to the gym two times per week, and has lost over 10 pounds. he has a good energy level and his ecog performance status is 0. he denies any fever, chills, or night sweats. no lymphadenopathy. no nausea or vomiting. no change in bowel or bladder habits.,current medications: , multivitamin q.d., aspirin one tablet q.d., lupron q. three months, flomax 0.4 mg q.d., and warfarin 2.5 mg q.d.,allergies: ,no known drug allergies.,review of systems: , as per the hpi, otherwise negative.,past medical history:,1. he is status post left inguinal hernia repair.,2. prostate cancer diagnosed in december 2004, which was a gleason 3+4. he is now receiving lupron.,social history: , he has a very remote history of tobacco use. he has one to two alcoholic drinks per day. he is married.,family history: , his brother had prostate cancer.,physical exam:,vit:

chief complaint: , cough and abdominal pain for two days.,history of present illness: , this is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. the patient stated that the abdominal pain was only associated with coughing. the patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,past medical history: ,significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,past surgical history: ,the patient had bilateral cataract extractions in 2007, appendectomy as a child, and three d&cs in the past secondary to miscarriages.,medications: , on presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily. the patient also takes multivitamin and lutein over-the-counter for macular degeneration.,allergies: , the patient has no known drug allergies.,family history:, mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,social history:, the patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. denies any alcohol use. denies any iv drug use.,physical examination: ,general: this is a 76-year-old female, well nourished. vital signs: on presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20. heent: anicteric sclerae. conjunctivae pink. throat was clear. mucosal membranes were dry. chest: coarse breath sounds bilaterally at the bases. cardiac: s1 and s2. no murmurs, rubs or gallops. no evidence of carotid bruits. abdomen: positive bowel sounds, presence of soreness on examination in the abdomen on palpation. there is no rebound or guarding. extremities: no clubbing, cyanosis or edema.,hospital course: , the patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes. there is no evidence of effusion or consolidation. degenerative changes were seen in the shoulder. the patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern. urinalysis showed no evidence of infection as well as her influenza a&b were negative. preliminary blood cultures have been with no growth to date status post 48 hours. the patient was started on cefepime 1 g iv q.12h. and given iv hydration. she has also been on xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol. in terms of prophylactic measures, she received lovenox subcutaneously for dvt prophylaxis. currently today, she feels much improved with still only a mild cough. the patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18. her white count on presentation was 13.6 and yesterday's white count was 10.3.,final diagnosis:, bronchitis.,disposition: , the patient will be going home.,medications: , hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily. also, avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,diet:, to follow a low-salt diet.,activity:, as tolerated.,followup: ,to follow up with dr. abc in two weeks.

chief complaint:, congestion, tactile temperature.,history of present illness: , the patient is a 21-day-old caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). one day ago, mom also noticed a tactile temperature and gave the patient tylenol.,baby also has had some decreased p.o. intake. his normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. he sleeps well, but has been more tired and has been fussy over the past 2 days. the parents noticed no improvement with albuterol treatments given in the er. his urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. mom denies any diarrhea. his bowel movements are yellow colored and soft in nature.,the parents also noticed no rashes, just his normal neonatal acne. the parents also deny any vomiting, apnea.,emergency room course: , in the er, the patient received a lumbar puncture with csf fluid sent off for culture and cell count. this tap was reported as clear, then turning bloody in nature. the patient also received labs including a urinalysis and urine culture, bmp, cbc, crp, blood culture. this patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,review of systems: , see above history of present illness. mom's nipples are currently cracked and bleeding. mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. he is status post a circumcision. otherwise, review of systems is negative.,birth/past medical history: , the patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat c-section. mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). gbs status was negative. mom smoked up to the last 5 months of the pregnancy. mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. mom and baby were both discharged out of the hospital last 48 hours. this patient has received no hospitalizations so far.,past surgical history:, circumcision.,allergies: , no known drug allergies.,medications:, tylenol.,immunizations:, none of the family members this year have received a flu vaccine.,social history:, at home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother. both brothers at home are sick with cold symptoms including diarrhea and vomiting. the brother (2-1/2-year-old) was seen in the er tonight with this patient and discharged home with an albuterol prescription. a nephew of the mom with an ear infection. mom also states that she herself was sick with the flu soon after delivery. there has been recent travel exposure to dad's family over the christmas holidays. at this time, there is also exposure to indoor cats and dogs. this patient also has positive smoking exposure coming from mom.,family history: , paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. there are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,physical examination: ,vitals: temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with o2 saturations 97 to 100% on room air. weight was 4.1 kg.,general: not in acute distress, sneezing, positive congestion with breaths taken.,heent: normocephalic, atraumatic head. anterior fontanelle was soft, open, and flat. bilateral red reflexes were positive. oropharynx is clear with palate intact, negative rhinorrhea.,cardiovascular: heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature. capillary refill was less than 3 seconds.,lungs: positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,abdomen: bowel sounds are positive, nontender, soft, negative hepatosplenomegaly. umbilical site was with scant dried yellow discharge.,gu: tanner stage 1 male, circumcised. there was mild hyperemia to the penis with some mild yellow dried discharge.,hips: negative barlow or ortolani maneuvers.,skin: positive facial erythema toxicum.,laboratory data: , cbc drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes. the hemoglobin was 14.4, hematocrit was 40. the platelet count was elevated at 698,000. a crp was less than 0.3.,a hemolyzed bmp sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and bun of 4, creatinine 0.4, and a glucose of 66.,a cath urinalysis was negative.,a csf sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per er personnel), csf glucose was 41, csf protein was 89. a gram stain showed rare white blood cells, many red blood cells, no organisms.,assessment: , a 21-day-old with:,1. rule out sepsis.,2. possible upper respiratory infection.,given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever. the bacterial considerations although to consider in this child include group b streptococcus, e. coli, and listeria. we should also consider herpes simplex virus, although these 3200 red blood cells from his csf could be due to his bloody tap in the er. also, there is not a predominant lymphocytosis of his csf sample (there is 0 white blood cell count in the cell count).,also to consider in this child is rsv. the patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use. also, there is negative apnea in this patient.,plan: ,1. we will place this patient on the rule out sepsis pathway including iv antibiotics, ampicillin and gentamicin for at least 48 hours.,2. we will follow up with his blood, urine, and csf cultures.

final diagnoses:,1. herniated nucleuses pulposus, c5-6 greater than c6-7, left greater than c4-5 right with left radiculopathy.,2. moderate stenosis c5-6.,operation: , on 06/25/07, anterior cervical discectomy and fusions c4-5, c5-6, c6-7 using bengal cages and slimlock plate c4 to c7; intraoperative x-ray.,this is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches." in the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right. he has some neck pain at times and has seen dr. x for an epidural steroid injection, which was very helpful. more recently he saw dr. y and went through some physical therapy without much relief.,cervical mri scan was obtained and revealed a large right-sided disc herniation at c4-5 with significant midline herniations at c5-6 and a large left hnp at c6-7. in view of the multiple levels of pathology, i was not confident that anything short of surgical intervention would give him significant relief. the procedure and its risk were fully discussed and he decided to proceed with the operation.,hospital course: , following admission, the procedure was carried out without difficulty. blood loss was about 125 cc. postop x-ray showed good alignment and positioning of the cages, plate, and screws. after surgery, he was able to slowly increase his activity level with assistance from physical therapy. he had some muscle spasm and soreness between the shoulder blades and into the back part of his neck. he also had some nausea with the pca. he had a low-grade fever to 100.2 and was started on incentive spirometry. over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,by 06/27/07, he was ready to go home. he has been counseled regarding wound care and has received a neck sheet for instruction. he will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks. he has prescriptions for lortab 7.5 mg and robaxin 750 mg. he is to call if there are any problems.

procedure in detail: , following premedication with vistaril 50 mg and atropine 0.4 mg im, the patient received versed 5.0 mg intravenously after cetacaine spray to the posterior palate. the olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. the upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal. no evidence of friability, ulceration or tumor mass was encountered. the instrument was withdrawn to the antrum, and biopsies taken for clo testing, and then the instrument removed.

subjective:, the patient returns to the pulmonary medicine clinic for followup evaluation of copd and emphysema. she was last seen in the clinic in march 2004. since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. she is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself.,at the present time, respiratory status is relatively stable. she is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. she does have occasional cough and a small amount of sputum production. no fever or chills. no chest pains.,current medications:, the patient’s current medications are as outlined.,allergies to medications:, erythromycin.,review of systems:, significant for problems with agitated depression. her respiratory status is unchanged as noted above.,examination:,general: the patient is in no acute distress.,vital signs: blood pressure is 152/80, pulse 80 and respiratory rate 16.,heent: nasal mucosa was mild-to-moderately erythematous and edematous. oropharynx was clear.,neck: supple without palpable lymphadenopathy.,chest: chest demonstrates decreased breath sounds throughout all lung fields, coarse but relatively clear.,cardiovascular: distant heart tones. regular rate and rhythm.,abdomen: soft and nontender.,extremities: without edema.,oxygen saturation was checked today on room air, at rest it was 90%.,assessment:,1. chronic obstructive pulmonary disease/emphysema, severe but stable.,2. mild hypoxemia, however, oxygen saturation at rest is stable without supplemental oxygen.,3. history of depression and schizophrenia.,plan:, at this point, i have recommended that she continue current respiratory medicine. i did suggest that she would not use her oxygen when she is simply sitting, watching television or reading. i have recommended that she use it with activity and at night. i spoke with her about her living situation. encouraged her to speak with her family, as well as primary care physician about making efforts for her to return to her apartment. follow up evaluation is planned in pulmonary medicine clinic in approximately three months or sooner if need be.

exam:,mri left shoulder,clinical:,this is a 69-year-old male with pain in the shoulder. evaluate for rotator cuff tear.,findings:,examination was performed on 9/1/05.,there is marked supraspinatus tendinosis and extensive tearing of the substance of the tendon and articular surface, extending into the myotendinous junction as well. there is still a small rim of tendon along the bursal surface, although there may be a small tear at the level of the rotator interval. there is no retracted tendon or muscular atrophy (series #6 images #6-17).,normal infraspinatus tendon.,there is subscapularis tendinosis with fraying and partial tearing of the superior most fibers extending to the level of the rotator interval (series #9 images #8-13; series #3 images #8-14). there is no complete tear, gap or fiber retraction and there is no muscular atrophy.,there is tendinosis and superficial tearing of the long biceps tendon within the bicipital groove, and there is high grade (near complete) partial tearing of the intracapsular portion of the tendon. the biceps anchor is intact. there are degenerative changes in the greater tuberosity of the humerus but there is no fracture or subluxation.,there is degeneration of the superior labrum and there is a small nondisplaced tear in the posterior superior labrum at the one to two o’clock position (series #6 images #12-14; series #3 images #8-10; series #9 images #5-8). there is a small sublabral foramen at the eleven o’clock position (series #9 image #6). there is no osseous bankart lesion.,normal superior, middle and inferior glenohumeral ligaments.,there is hypertrophic osteoarthropathy of the acromioclavicular joint with narrowing of the subacromial space and flattening of the superior surface of the supraspinatus musculotendinous junction, which in the appropriate clinical setting is an mri manifestation of an impinging lesion (series #8 images #3-12).,normal coracoacromial, coracohumeral and coracoclavicular ligaments. there is minimal fluid within the glenohumeral joint. there is no atrophy of the deltoid muscle.,impression:, there is extensive supraspinatus tendinosis and partial tearing as described. there is no retracted tendon or muscular atrophy, but there may be a small tear along the anterior edge of the tendon at the level of the rotator interval, and this associated partial tearing of the superior most fibers of the subscapularis tendon. there is also a high-grade partial tear of the long biceps tendon as it courses under the transverse humeral ligament. there is no evidence of a complete tear or retracted tendon. small nondisplaced posterior superior labral tear. outlet narrowing from the acromioclavicular joint, which in the appropriate clinical setting is an mri manifestation of an impinging lesion.

cc:, found unresponsive.,hx: , 39 y/o rhf complained of a severe ha at 2am 11/4/92. it was unclear whether she had been having ha prior to this. she took an unknown analgesic, then vomited, then lay down in bed with her husband. when her husband awoke at 8am he found her unresponsive with "stiff straight arms" and a "strange breathing pattern." a brain ct scan revealed a large intracranial mass. she was intubated and hyperventilated to abg (7.43/36/398). other local lab values included: wbc 9.8, rbc 3.74, hgb 13.8, hct 40.7, cr 0.5, bun 8.5, glucose 187, na 140, k 4.0, cl 107. she was given mannitol 1gm/kg iv load, dph 20mg/kg iv load, and transferred by helicopter to uihc.,pmh:, 1)myasthenia gravis for 15 years, s/p thymectomy,meds:, imuran, prednisone, mestinon, mannitol, dph, iv ns,fhx/shx:, married. tobacco 10 pack-year; quit nearly 10 years ago. etoh/substance abuse unknown.,exam:, 35.8f, 99bpm, bp117/72, mechanically ventilated at a rate of 22rpm on !00%fio2. unresponsive to verbal stimulation. cn: pupils 7mm/5mm and unresponsive to light (fixed). no spontaneous eye movement or blink to threat. no papilledema or intraocular hemorrhage noted. trace corneal reflexes bilaterally. no gag reflex. no oculocephalic reflex. motor/sensory: no spontaneous movement. on noxious stimulation (deep nail bed pressure) she either extended both upper extremities (rue>lue), or withdrew the stimulated extremity (right > left). gait/station/coordination no tested. reflexes: 1+ on right and 2+ on left with bilateral babinski signs.,hct 11/4/92: large heterogeneous mass in the right temporal-parietal region causing significant parenchymal distortion and leftward subfalcine effect . there is low parenchymal density within the white matter. a hyperdense ring lies peripherally and may represent hemorrhage or calcification. the mass demonstrates inhomogeneous enhancement with contrast.,course:, head of bed elevated to 30 degrees, mannitol and dph were continued. mri of brain demonstrated a large right parietal mass with necrotic appearing center and leftward shift of midline structures. she underwent surgical resection of the tumor. pathological analysis was consistent with adenocarcinoma. gyn exam, ct abdomen and pelvis, bone scan were unremarkable. cxr revealed an right upper lobe lung nodule. she did not undergo thoracic biopsy due to poor condition. she received 3000 cgy cranial xrt in ten fractions and following this was discharged to a rehabilitation center.,in march, 1993 the patient exhibited right ptosis, poor adduction and abduction od, 4/4 strength in the upper extremities and 5-/5- strength in the lower extremities. she was ambulatory with an ataxic gait.,she was admitted on 7/12/93 for lower cervical and upper thoracic pain, paraparesis and t8 sensory level. mri brainstem/spine on that day revealed decreased t1 signal in the c2, c3, c6 vertebral bodies, increased t2 signal in the anterior medulla, and tectum, and spinal cord (c7-t3). following injection of gadolinium there was diffuse leptomeningeal enhancement from c7-t7 these findings were felt consistent with metastatic disease including possible leptomeningeal spread. neurosurgery and radiation oncology agreed that the patients symptoms could be due to either radiation injury and/or metastasis. the patient was treated with decadron and analgesics and discharged to a hospice center (her choice). she died a few months later.

history of present illness: , the patient is a 45-year-old male complaining of abdominal pain. the patient also has a long-standing history of diabetes which is treated with micronase daily.,past medical history: , there is no significant past medical history noted today.,physical examination:,heent: patient denies ear abnormalities, nose abnormalities and throat abnormalities.,cardio: patient has history of elevated cholesterol, but does not have ashd, hypertension and pvd.,resp: patient denies asthma, lung infections and lung lesions.,gi: patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,gu: patient has history of urinary tract disorder, but does not have bladder disorder and kidney disorder.,endocrine: patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,dermatology: patient denies allergic reactions, rashes and skin lesions.,meds:, micronase 2.5 mg tab po qam #30. bactrim 400/80 tab po bid #30.,social history:, no known history of drug or alcohol abuse. work, diet, and exercise patterns are within normal limits.,family history:, no significant family history.,review of systems:, non-contributory.,vital signs: height = 72 in. weight =184 lbs. upright bp = 120/80 mmhg. pulse = 80 bpm. resp =12 pm. patient is afebrile.,neck: the neck is supple. there is no jugular venous distension. the thyroid is nontender, or normal size and conto.,lungs: lung expansion and excursions are symmetric. the lungs are clear to auscultation and percussion.,cardio: there is a regular rhythm. si and s2 are normal. no abnormal heart sounds are detected. blood pressure is equal bilaterally.,abdomen: normal bowel sounds are present. the abdomen is soft; the abdomen is nontender; without organomegaly; there is no cva tenderness. no hernias are noted.,extremities: there is no clubbing, cyanosis, or edema.,assessment: , diabetes type ii uncontrolled. acute cystitis.,plan: , endocrinology consult, complete cbc. ,rx: , micronase 2.5 mg tab po qam #30, bactrim 400/80 tab po bid #30.

cc:, lethargy.,hx:, this 28y/o rhm was admitted to a local hospital on 7/14/95 for marked lethargy. he had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. on the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. he denied fevers, chills, sweats, cough, cp, sob or diarrhea. upon evaluation locally, he had a temperature of 99.5f and appeared lethargic. he also had anisocoria with left pupil 0.5mm bigger than the right. there was also question of left facial weakness. an mri was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. he was given 10mg of iv decardron,100gm of iv mannitol, intubated and hyperventilated and transferred to uihc.,he was admitted to the department of medicine on 7/14/95, and transferred to the department of neurology on 7/17/95, after being extubated.,meds on admission:, bactrim ds qd, diflucan 100mg qd, acyclovir 400mg bid, xanax, stavudine 40mg bid, rifabutin 300mg qd.,pmh:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) hiv/aids dx 1991. he was initially treated with azt, then ddi. he developed chronic diarrhea and was switched to d4t in 1/95. however, he developed severe neuropathy and this was stopped 4/95. the diarrhea recured. he has acyclovir resistant genital herpes and generalized psoriasis. he most recent cd4 count (within 1 month of admission) was 20.,fhx:, htn and multiple malignancies of unknown type.,shx:, homosexual, in monogamous relationship with an hiv infected partner for the past 3 years.,exam: ,7/14/95 (by internal medicine): bp134/80, hr118, rr16 on vent, 38.2c, intubated.,ms: somnolent, but opened eyes to loud voices and would follow most commands.,cn: pupils 2.5/3.0 and "equally reactive to light." mild horizontal nystagmus on rightward gaze. eom were otherwise intact.,motor: moved 4 extremities well.,sensory/coord/gait/station/reflexes: not done.,gen exam: penil ulcerations.,exam:, 7/17/96 (by neurology): bp144/73, hr59, rr20, 36.0, extubated.,ms: alert and mildly lethargic. oriented to name only. thought he was a local hospital and that it was 1/17/1994. did not understand he had a brain lesion.,cn: pupils 6/5.5 decreasing to 4/4 on exposure to light. eom were full and smooth. no rapd or light-near dissociation. papilledema (ou). right lower facial weakness and intact facial sensation to pp testing. gag-shrug and corneal responses were intact, bilaterally. tongue midline.,motor: grade 5- strength on the right side.,sensory: no loss of sensation on pp/vib/prop testing.,coord: reduced speed and accuracy on right fnf and right hks movements.,station: rue pronator drift.,gait: not done.,reflexes: 2+/2 throughout. babinski sign present on right and absent on left.,gen exam: unremarkable except for the genital lesion noted by internal medicine.,course:, the outside mri was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. the mass inhomogenously enhanced with gadolinium contrast.,the findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. he refused brain biopsy and was started on empiric treatment for toxoplasmosis. this consisted of pyrimethamine 75mg qd and sulfadiazine 2 g bid. he later became dnr and was transferred at his and his partner's request back to a local hospital.,he never returned for follow-up.

chief complaint:,1. chronic lymphocytic leukemia (cll).,2. autoimmune hemolytic anemia.,3. oral ulcer.,history of present illness: , the patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in may 2008. he was noted to have autoimmune hemolytic anemia at the time of his cll diagnosis. he has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day. he comes in to clinic today for follow-up and complete blood count. at his last office visit we discontinued this prophylactic antivirals and antibacterial.,current medications:, prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., lopressor 75 mg q.d., vitamin c 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,allergies: ,vicodin.,review of systems: ,the patient reports ulcer on his tongue and his lip. he has been off of valtrex for five days. he is having some difficulty with his night vision with his left eye. he has a known cataract. he denies any fevers, chills, or night sweats. he continues to have headaches. the rest of his review of systems is negative.,physical exam:,vitals:

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

history:, a is a 55-year-old who i know well because i have been taking care of her husband. she comes for discussion of a screening colonoscopy. her last colonoscopy was in 2002, and at that time she was told it was essentially normal. nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy. i told her that the interval was appropriate and that it made sense to do so. she denies any significant weight change that she cannot explain. she has had no hematochezia. she denies any melena. she says she has had no real change in her bowel habit but occasionally does have thin stools.,past medical history:, on today's visit we reviewed her entire health history. surgically she has had a stomach operation for ulcer disease back in 1974, she says. she does not know exactly what was done. it was done at a hospital in california which she says no longer exists. this makes it difficult to find out exactly what she had done. she also had her gallbladder and appendix taken out in the 1970s at the same hospital. medically she has no significant problems and no true medical illnesses. she does suffer from some mild gastroparesis, she says.,medications: , reglan 10 mg once a day.,allergies: , she denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,social history: , she still smokes one pack of cigarettes a day. she was counseled to quit. she occasionally uses alcohol. she has never used illicit drugs. she is married, is a housewife, and has four children.,family history: , positive for diabetes and cancer.,review of systems: , essentially as mentioned above.,physical examination:,general: a is a healthy appearing female in no apparent distress.,vital signs: her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees f.,heent: no cervical bruits, thyromegaly, or masses. she has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,lungs: clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,heart: regular rate and rhythm without murmur, rub, or gallop.,abdomen: soft, nontender, nondistended.,extremities: no cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,neuro: no focal deficits, is intact to soft touch in all four.,assessment and recommendations: , in light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy. we do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers. she also complains of significant reflux and has not had an upper endoscopy in over five to six years as well. i discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,we will schedule her for an upper and lower endoscopy at her convenience.

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

diagnosis:, status post brain tumor removal.,history:, the patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. the patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. the patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. the patient reports that she was admitted to hospital on 12/05/08. at that time, they found massive swelling on the brain and a second surgery was performed. the patient then remained in acute rehab until she was discharged to home on 01/05/09. the patient's husband, al, is also present and he reports that during rehabilitation the patient did have a dvt in the left calf that has since been resolved.,past medical history: , unremarkable.,medications: ,coumadin, keppra, decadron, and glucophage.,subjective: , the patient reports that the pain is not an issue at this time. the patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.,patient goal: ,to increase strength in her left leg for better balance and walking.,objective:,range of motion: bilateral lower extremities are within normal limits.,strength: bilateral lower extremities are grossly 5/5 with one repetition, except left hip reflexion 4+/5.,balance: the patient's balance was assessed with a berg balance test. the patient has got 46/56 points, which places her at moderate risk for falls.,gait: the patient ambulates with contact guard assist. the patient ambulates with a reciprocal gait pattern with good bilateral foot clearance. however, the patient has been reports that with increased fatigue, left footdrop tends to occur. a 6-minute walk test will be performed at the next visit due to time constraints.,assessment: , the patient is a 64-year-old female referred to physical therapy status post brain surgery. examination indicates deficits in strength, balance, and ambulation. the patient will benefit from skilled physical therapy to address these impairments.,treatment plan: , the patient will be seen three times per week for 4 weeks and then reduce it to two times per week for 4 additional weeks. interventions include:,1. therapeutic exercise.,2. balance training.,3. gait training.,4. functional mobility training.,short term goal to be completed in 4 weeks:,1. the patient is to tolerate 30 repetitions of all lower extremity exercises.,2. the patient is to improve balance with a score of 50/56 points.,3. the patient is to ambulate 1000 feet in a 6-minute walk test with standby assist.,long term goal to be achieved in 8 weeks:,1. the patient is to ambulate independently within her home and standby to general supervision within the community.,2. berg balance test to be 52/56.,3. the patient is to ambulate a 6-minute walk test for 1500 feet independently including safe negotiation of corners and busy areas.,4. the patient is to demonstrate safely stepping over and around objects without loss of balance.,prognosis for the above-stated goals is good. the above treatment plan has been discussed with the patient and her husband. they are in agreement.

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

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.

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.

diagnosis:,1. broad-based endocervical poly.,2. broad- based pigmented, raised nevus, right thigh.,operation:,1. leep procedure of endocervical polyp.,2. electrical excision of pigmented mole of inner right thigh.,findings: , there was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop. also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,procedure: , with the patient in the supine position, general anesthesia was administered. the patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,an insulated posterior weighted retractor was put in. using the leep tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation. the endocervical polyp on the posterior lip of the cervix was excised.,then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding. the wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop. cautery of the base was done, and then it was closed with figure-of-eight 3-0 vicryl sutures. a band-aid was applied over this.,rechecking the cervix, no bleeding was noted. the patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.

reason for visit:, six-month follow-up visit for cad.,he is a 67-year-old man who suffers from chronic anxiety and coronary artery disease and djd.,he has been having a lot of pain in his back and pain in his left knee. he is also having trouble getting his nerves under control. he is having stomach pains and occasional nausea. his teeth are bad and need to be pulled.,he has been having some chest pains, but overall he does not sound too concerning. he does note some more shortness of breath than usual. he has had no palpitations or lightheadedness. no problems with edema.,medications:, lipitor 40 mg q.d., metoprolol 25 mg b.i.d., plavix 75 mg q.d-discontinued, enalapril 10 mg b.i.d., aspirin 325 mg-reduced to 81 mg, lorcet 10/650-given a 60 pill prescription, and xanax 0.5 mg b.i.d-given a 60 pill prescription.,review of systems: , otherwise unremarkable.,pex:, bp: 140/78. hr: 65. wt: 260 pounds (which is up one pound). there is no jvd. no carotid bruit. cardiac: regular rate and rhythm and distant heart sounds with a 1/6 murmur at the upper sternal border. lungs: clear. abdomen: mildly tender throughout the epigastrium.,extremities: no edema.,ekg:, sinus rhythm, left axis deviation, otherwise unremarkable.,echocardiogram (for dyspnea and cad): normal systolic and diastolic function. moderate lvh. possible gallstones seen.,impression:,1. cad-status post anterior wall mi 07/07 and was found to a have multivessel cad. he has a stent in his lad and his obtuse marginal. fairly stable.,2. dyspnea-seems to be due to his weight and the disability from his knee. his echocardiogram shows no systolic or diastolic function.,3. knee pain-we well refer to scotland orthopedics and we will refill his prescription for lorcet 60 pills with no refills.,4. dyslipidemia-excellent numbers today with cholesterol of 115, hdl 45, triglycerides 187, and ldl 33, samples of lipitor given.,5. panic attacks and anxiety-xanax 0.5 mg b.i.d., 60 pills with no refills given.,6. abdominal pain-asked to restart his omeprazole and i am also going to reduce his aspirin to 81 mg q.d.,7. prevention-i do not think he needs to be on the plavix any more as he has been relatively stable for two years.,plan:,1. discontinue plavix.,2. aspirin reduced to 81 mg a day.,3. lorcet and xanax prescriptions given.,4. refer over to scotland orthopedics.,5. peridex mouthwash given for his poor dentition and told he was cardiovascularly stable and have his teeth extracted.

operations/procedures,1. insertion of right internal jugular tessio catheter.,2. placement of left wrist primary submental arteriovenous fistula.,procedure in detail: , the patient was brought to the operating room and placed in the supine position. adequate general endotracheal anesthesia was induced. appropriate monitoring lines were placed. the right neck, chest and left arm were prepped and draped in a sterile fashion. a small incision was made at the top of the anterior jugular triangle in the right neck. through this small incision, the right internal jugular vein was punctured and a guidewire was placed. it was punctured a 2nd time, and a 2nd guidewire was placed. the tessio catheters were assembled. they were measured for length. counter-incisions were made on the right chest. they were then tunneled through these lateral chest wall incisions to the neck incision, burying the dacron cuffs. they were flushed with saline. a suture was placed through the guidewire, and the guidewire and dilator were removed. the arterial catheter was then placed through this, and the tear-away introducer was removed. the catheter aspirated and bled easily. it was flushed with saline and capped. this was repeated with the venous line. it also aspirated easily and was flushed with saline and capped. the neck incision was closed with a 4-0 tycron, and the catheters were sutured at the exit sites with 4-0 nylon. dressings were applied. an incision was then made at the left wrist. the basilic vein was dissected free, as was the radial artery. heparin was given, 50 mg. the radial artery was clamped proximally and distally with a bulldog. it was opened with a #11 blade and potts scissors, and stay sutures of 5-0 prolene were placed. the vein was clipped distally, divided and spatulated for anastomosis. it was sutured to the radial artery with a running 7-0 prolene suture. the clamps were removed. good flow was noted through the artery. protamine was given, and the wound was closed with interrupted 3-0 dexon subcutaneous and a running 4-0 dexon subcuticular on the skin. the patient tolerated the procedure well.

chief complaint: , motor vehicle accident.,history of present illness: , this is a 32-year-old hispanic female who presents to the emergency department today via ambulance. the patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. the patient states that she was driving her vehicle at approximately 40 miles per hour. the patient was driving a minivan. the patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. the patient states that she was wearing her seatbelt. she was driving. there were no other passengers in the van. the patient states that she was restrained by the seatbelt and that her airbag deployed. the patient denies hitting her head. she states that she does have some mild pain on the left aspect of her neck. the patient states that she believes she may have passed out shortly after the accident. the patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. the patient denies any pain in her knees, ankles, or feet. she denies any pain in her shoulders, elbows, and wrists. the patient does state that she is somewhat painful throughout the bones of her pelvis as well. the patient did not walk after this accident. she was removed from her car and placed on a backboard and immobilized. the patient denies any chest pain or difficulty breathing. she denies any open lacerations or abrasions. the patient has not had any headache, nausea or vomiting. she has not felt feverish or chilled. the patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. there were no oblique vectors or force placed on this accident. the patient had straight rear-ending of the vehicle in front of her. the pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. the patient states that her last menstrual cycle was at the end of may. she does not believe that she could be pregnant. she is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on accutane.,past medical history:, no significant medical history other than acne.,past surgical history:, none.,social habits: , the patient denies tobacco, alcohol or illicit drug usage.,medications:, accutane.,allergies: , no known medical allergies.,family history: , noncontributory.,physical examination:,general: this is a hispanic female who appears her stated age of 32 years. she is well-nourished, well-developed, in no acute distress. the patient is pleasant. she is immobilized on a backboard and also her cervical spine is immobilized as well on a collar. the patient is without capsular retractions, labored respirations or accessory muscle usage. she responds well and spontaneously.,vital signs: temperature 98.2 degrees fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,heent: head is normocephalic. there is no crepitus. no bony step-offs. there are no lacerations on the scalp. sclerae are anicteric and noninjected. fundoscopic exam appears normal without papilledema. external ocular movements are intact bilaterally without nystagmus or entrapment. nares are patent and free of mucoid discharge. mucous membranes are moist and free of exudate or lesions.,neck: supple. no thyromegaly. no jvd. no carotid bruits. trachea is midline. there is no stridor.,heart: regular rate and rhythm. clear s1 and s2. no murmur, rub or gallop is appreciated.,lungs: clear to auscultation bilaterally. no wheezes, rales, or rhonchi.,abdomen: soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants. there is no organomegaly here. positive bowel sounds are auscultated throughout. there is no rigidity or guarding. negative cva tenderness bilaterally.,extremities: no edema. there are no bony abnormalities or deformities.,peripheral vascular: capillary refill is less than two seconds in all extremities. the patient does have intact dorsalis pedis and radial pulses bilaterally.,psychiatric: alert and oriented to person, place, and time. the patient recalls all events regarding the accident today.,neurologic: cranial nerves ii through xii are intact bilaterally. no focal deficits are appreciated. the patient has equal and strong distal and proximal muscle group strength in all four extremities. the patient has negative romberg and negative pronator drift.,lymphatics: no appreciable adenopathy.,musculoskeletal: the patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists. there are no bony abnormalities identified. the patient does have some mild tenderness over palpation of the bilateral iliac crests.,skin: warm, dry, and intact. no lacerations. there are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus. no lacerations and no sites of trauma or bleeding are identified.,diagnostic studies: , the patient does have multiple x-rays done. there is an x-ray of the pelvis, which shows normal pelvis and right hip. there is also a ct scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine. there is some prevertibral soft tissue swelling from c5 through c7. this is nonspecific and could be due to prominence of upper esophageal sphincter. the ct scan of the brain without contrast shows no evidence of acute intracranial injury. there is some mucus in the left sphenoid sinus. the patient also has emergent ct scan without contrast of the abdomen. the initial studies show some dependent atelectasis in both lungs. there is also some low density in the liver, which could be from artifact or overlying ribs; however, a ct scan with contrast is indicated. a ct scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities. the patient has laboratory studies done as well. cbc is within normal limits without anemia, thrombocytopenia or leukocytosis. the patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,emergency department course: , the patient was removed from the backboard within the first half hour of her emergency department stay. the patient has no significant bony deformities or abnormalities. the patient is given a dose of tylenol here in the emergency department for treatment of her pain. her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. the patient's ct scans of the abdomen appeared normal. she has no signs of bleeding. i believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. the patient is able to stand and walk through the emergency department without difficulty. she has no abrasions or lacerations.,assessment and plan:, multiple contusions and abdominal pain, status post motor vehicle collision. plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her ct scans. she has normal scans of the brain and her c-spine as well. the patient is in stable condition. she will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting. the patient is given a prescription for vicodin and flexeril to use it at home for her muscular pain.

preoperative diagnoses: , left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,postoperative diagnoses:, left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,procedure: ,cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,anesthesia: ,general endotracheal anesthetic with a caudal block x2.,fluids received: ,1000 ml crystalloid.,estimated blood loss: ,less than 10 ml.,specimens: , tissue sent to pathology is a renal biopsy.,abnormal findings: , a stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,tubes and drains: ,a 10-french silicone foley catheter with 3 ml in balloon and a 4.7-french ureteral double j-stent multilength.,indications for operation: ,the patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by dr. chang. it was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction. plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,description of operation: ,the patient was taken to the operative room. surgical consent, operative site, and patient identification were verified. dr. x and dr. y both agreed upon the procedures in advance. dr. y then, once the patient was anesthetized, requested iv antibiotics with fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position. dr. y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 french. the 9.5-french cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis. i was able to locate the ureteral orifice bilaterally, although no urine coming from the right. we then placed a 4-french ureteral catheter into the ureter as far as we could go. an antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter. a retrograde was performed, and it was found that there was a narrowed band across the two. upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all. dr. y then placed a 0.035 guidewire into the ureter after removing the 4-french catheter and then placed a 4.7-french double-j catheter into the ureter as far as it would go allowing it to coil in the bladder. once this was completed, we then removed the cystoscope and sheath, placed a 10-french foley catheter, and the patient was positioned by dr. x and dr. y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll. he was then sterilely prepped and draped. dr. y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and dr. x performed cautery of the areas advanced to be excised. once this was then dissected, dr. y and dr. x divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________. at this point, dr. x used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia. dr. y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum. dr. x and dr. y also needed dissection on the medial and lateral aspects with dr. y being on the lateral aspect of the area and dr. x on the medial to get an adequate length of this. the tissue was markedly inflamed and had significant adhesions noted. the patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction. ultimately, dr. y and dr. x both with alternating dissection were able to dissect the renal pelvis to a position where dr. y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter. dr. x then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture. dr. y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder. dr. y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed. dr. y then placed interrupted sutures of 5-0 monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair. dr. x then was able to without much difficulty do interrupted sutures on the medial aspect. the stent was then placed into the bladder in the proper orientation and alternating sutures by dr. y and dr. x closed the ureteropelvic junction without any evidence of leakage. once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position. this opening was at least 1.5 cm wide. dr. y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health. electrocautery was used on the base. there was no bleeding, however, and the tissue was quite soft. dermabond and gelfoam were placed, and then dr. y closed the biopsy site over with thrombin-gelfoam using the 2-0 chromic stay sutures. dr. x then closed the fascial layers with running suture of 3-0 vicryl in 3 layers. dr. y closed the scarpa fascia and the skin with 4-0 vicryl and 4-0 rapide respectively. a 4-0 nylon suture was then placed by dr. y around the previous nephrostomy tube, which was again left clamped. dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by dr. y over the nephrostomy tube site, which was left clamped, and the patient then had a foley catheter placed in the bladder. the foley catheter was then taped to his leg. a second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.

diagnoses:,1. bronchiolitis, respiratory syncytial virus positive; improved and stable.,2. innocent heart murmur, stable.,hospital course: , the patient was admitted for an acute onset of congestion. she was checked for rsv, which was positive and admitted to the hospital for acute bronchiolitis. she has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as rsv bronchiolitis typically worsens the third and fourth day of illness. she was treated per pathway orders. however, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission. there was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained. we did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe. however, the rest of the lungs were normal and the heart was also normal. there were no complications during her hospitalization and she continued to be stable and eating better. on day 2 of the admission, it was decided she was okay to go home. mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this. during her hospitalization, albuterol mdi was given to the patient and more for mom to learn outpatient care. the patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,discharge physical examination:,vital signs: she is afebrile. vital signs were stable within normal limits on room air.,general: she is sleeping and in no acute distress.,heent: her anterior fontanelle was soft and flat. she does have some upper airway congestion.,cardiovascular: regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,extremities: her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,lungs: her lungs did show some slight coarseness, but good air movement with equal breath sounds. she does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases. she did not have any respiratory distress while she was asleep.,abdomen: normal bowel sounds. soft and nondistended.,genitourinary: she is tanner i female.,discharge weight:, her weight at discharge 3.346 kg, which is up 6 grams from admission.,discharge instructions: , ,activity: no one should smoke near the patient. she should also avoid all other exposures to smoke such as from fireplaces and barbecues. she is to avoid contact with other infants since she is sick and they are to limit travel. there should be frequent hand washings.,diet: regular diet. continue breast-feeding as much as possible and encourage oral intake.,medications: she will be sent home on albuterol mdi to be used as needed for cough, wheezes or dyspnea.,additional instructions:, mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,

admission diagnoses,1. neck pain with right upper extremity radiculopathy.,2. cervical spondylosis with herniated nucleus pulposus c4-c5, c5-c6, and c6-c7 with stenosis.,discharge diagnoses,1. neck pain with right upper extremity radiculopathy.,2. cervical spondylosis with herniated nucleus pulposus c4-c5, c5-c6, and c6-c7 with stenosis.,operative procedures,1. anterior cervical discectomy with decompression c4-c5, c5-c6, and c6-c7.,2. arthrodesis with anterior interbody fusion c4-c5, c5-c6, and c6-c7.,3. spinal instrumentation c4 through c7.,4. implant.,5. allograft.,complications:, none.,course on admission: , this is the case of a very pleasant 41-year-old caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand. the patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now. the patient has been treated with medications, which has been unrelenting. the patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at c4-c5, c5-c6 and c6-c7. the patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with iv morphine. the patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger. the patient apparently is doing well with slight dysphagia, we treated her with decadron and we will send her home with medrol. the patient will have continued pain medication coverage with darvocet and flexeril. the patient will follow up with me as scheduled. instructions have been given.

preoperative diagnosis:, rhabdomyosarcoma of the left orbit.,postoperative diagnosis:, rhabdomyosarcoma of the left orbit.,procedure: , left subclavian vein mediport placement (7.5-french single-lumen).,indications for procedure: , this patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit. the patient is being taken to the operating room for mediport placement. she needs chemotherapy.,description of procedure: , the patient was taken to the operating room, placed supine, put under general endotracheal anesthesia. the patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion. an incision was made on the left shoulder area. the left subclavian vein was cannulated. the wire was passed, which was in good position under fluoro, using seldinger technique. near wire incision site made a pocket above the fascia and sutured in a size 7.5-french single-lumen mediport into the pocket in 4 places using 3-0 nurolon. i then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer. the line tip was in good position under fluoro. it withdrew and flushed well. i then closed the incision using 4-0 vicryl, 5-0 monocryl for the skin, and dressed with steri-strips. accessed the ports with a 1-inch 20-gauge huber needle, and it withdrew and flushed well with final heparin flush. we secured this with tegaderm. the patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by oncology.

psychosocial donor evaluation,following questions are mostly involved in a psychosocial donor evaluation:,a. decision to donate,what is your understanding of the recipient's illness and why a transplant is needed?,when and how did the subject of donation arise?,what was the recipient's reaction to your offer?,what are your family's feelings about your being a donor?,how did you arrive at the decision to be a donor?,how would your family and friends react if you decided not to be a donor?,how would you feel if you cannot be the donor for any reason?,what is your relationship to the recipient?,how will your relationship with the recipient change if you donate your kidney?,will your being a donor affect any other relationships in your life?,b. transplant issues,do you have an understanding of the process of transplant?,do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,have you thought about how you might feel if the kidney/liver is rejected?,do you have any doubts or concerns about donating?,do you understand that there will be pain and soreness after the transplant?,what are your expectations about your recuperation?,do you need to speak further to any of the transplant team members?,c. medical history,what previous illnesses or surgeries have you had? ,are you currently on any medications?,have you ever spoken with a counselor, a therapist or a psychiatrist?,do you smoke?,in a typical week, how many drinks do you consume? what drink do you prefer?,what kinds of recreational drugs have you tried? have you used any recently?,d. family and support system,with whom do you live? ,if you are in a relationship:,- length of the relationship: ,- name of spouse/partner: ,- age and health of spouse/partner: ,- children: ,e. post-surgical plans,with whom will you stay after discharge? ,what is your current occupation: ,do you have the support of your employer?

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.

subjective:, the patient complains of backache, stomachache, and dysuria for the last two days. fever just started today and cough. she has history of kidney stones less than a year ago and had a urinary tract infection at that time. her back started hurting last night.,past medical history:, she denies sexual activities since two years ago. her last menstrual period was 06/01/2004. her periods have been irregular. she started menarche at 10 years of age and she is still irregular and it runs in mom’s side of the family. mom and maternal aunt have had total hysterectomies. she also is diagnosed with abnormal valve has to be on sbe prophylaxis, sees dr. xyz allen. she avoids decongestants. she is limited on her activity secondary to her heart condition.,medication:, cylert.,allergies: , no known drug allergies.,objective:,vital signs: blood pressure is 124/72. temperature 99.2. respirations 20 unlabored. weight: 137 pounds.,heent: normocephalic. conjunctivae noninjected. no mattering noted. her tms are bilaterally clear, nonerythematous. throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,neck: supple. increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,respiratory: clear. no wheezes, no crackles, no tachypnea, and no retractions.,cardiovascular: regular rate and rhythm. s1 and s2 normal, no murmur.,abdomen: soft. no organomegaly. she did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable. she has no suprapubic tenderness.,extremities: she has good range of motion of upper and lower extremities. good ambulation.,her ua was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria. culture and sensitivity is pending. her strep test is negative. culture is pending.,assessment:,1. urinary dysuria.,2. left flank pain.,3. pharyngitis.,plan:, a 1 g of rocephin im was given. call dr. b's office tomorrow morning incase a second im dose is needed. if not then she will fill a prescription for omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug. push fluids. await strep culture report. follow up with dr. xyz if no better or symptoms worsen.

preoperative diagnoses,1. neck pain with bilateral upper extremity radiculopathy.,2. residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 with probable instability.,postoperative diagnoses,1. neck pain with bilateral upper extremity radiculopathy.,2. residual stenosis, c3-c4, c4-c5, c5-c6, and c6-c7 secondary to facet arthropathy with scar tissue.,3. no evidence of instability.,operative procedure performed,1. bilateral c3-c4, c4-c5, c5-c6, and c6-c7 medial facetectomy and foraminotomy with technical difficulty.,2. total laminectomy c3, c4, c5, and c6.,3. excision of scar tissue.,4. repair of dural tear with prolene 6-0 and tisseel.,fluids:, 1500 cc of crystalloid.,urine output: , 200 cc.,drains: , none.,specimens: , none.,complications: , none.,anesthesia:, general endotracheal anesthesia.,estimated blood loss:, less than 250 cc.,indications for the operation: ,this is the case of a very pleasant 41 year-old caucasian male well known to me from previous anterior cervical discectomy and posterior decompression. last surgery consisted of four-level decompression on 08/28/06. the patient continued to complain of posterior neck pain radiating to both trapezius. review of his mri revealed the presence of what still appeared to be residual lateral recess stenosis. it also raised the possibility of instability and based on this i recommended decompression and posterolateral spinal instrumention; however, intraoperatively, it appeared like there was no abnormal movement of any of the joint segments; however, there was still residual stenosis since the laminectomy that was done previously was partial. based on this, i did total decompression by removing the lamina of c3 through c6 and doing bilateral medial facetectomy and foraminotomy at c3-c4, c4-c5, c5-c6, and c6-c7 with no spinal instrumentation. operation and expected outcome risks and benefits were discussed with him prior to the surgery. risks include but not exclusive of bleeding and infection. infection can be superficial, but may also extend down to the epidural space, which may require return to the operating room and evacuation of the infection. there is also the risk of bleeding that could be superficial but may also be in the epidural space resulting in compression of spinal cord. this may result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function, which will require an urgent return to the operating room and evacuation of the hematoma. there is also the risk of a dural tear with its attendant problems of csf leak, headache, nausea, vomiting, photophobia, pseudomeningocele, and dural meningitis. this too may require return to the operating room for evacuation of said pseudomeningocele and repair. the patient understood the risk of the surgery. i told him there is just a 30% chance that there will be no improvement with the surgery; he understands this and agreed to have the procedure performed.,description of procedure: , the patient was brought to the operating room, awake, alert, not in any form of distress. after smooth induction and intubation, a foley catheter was inserted. monitoring leads were also placed by premier neurodiagnostics for both ssep and emg monitoring. the sseps were normal, and the emgs were silent during the entire case. after completion of the placement of the monitoring leads, the patient was then positioned prone on a wilson frame with the head supported on a foam facial support. shave was then carried out over the occipital and suboccipital region. all pressure points were padded. i proceeded to mark the hypertrophic scar for excision. this was initially cleaned with alcohol and prepped with duraprep.,after sterile drapes were laid out, incision was made using a scalpel blade #10. wound edge bleeders were carefully controlled with bipolar coagulation and a hot knife was utilized to excise the hypertrophic scar. dissection was then carried down to the cervical fascia, and by careful dissection to the scar tissue, the spinous process of c2 was then identified. there was absence of the spinous process of c3, c4, c5, and c6, but partial laminectomy was noted; removal of only 15% of the lamina. with this completed, we proceeded to do a total laminectomy at c3, c4, c5, and c6, which was technically difficult due to the previous surgery. there was also a dural tear on the right c3-c4 space that was exposed and repaired with prolene 6-0 and later with tisseel. by careful dissection and the use of a -5 and 3 mm bur, total laminectomy was done as stated with bilateral medial facetectomy and foraminotomy done at c3-c4, c4-c5, c5-c6, and c6-c7. there was significant epidural bleeding, which was carefully coagulated. at two points, i had to pack this with small pieces of gelfoam. after repair of the dural tear, valsalva maneuver showed no evidence of any csf leakage. area was irrigated with saline and bacitracin and then lined with tisseel. the wound was then closed in layers with vicryl 0 simple interrupted sutures to the fascia; vicryl 2-0 inverted interrupted sutures to the dermis and a running nylon 2-0 continuous vertical mattress stitch. the patient was extubated and transferred to recovery.

history of present illness: , the patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia. he states that he was in his usual state of health when he awoke one morning in january 2009. he had double vision. he states when he closed each eye, the double vision dissipated. the double vision entirely dissipated within one hour. he was able to drive. however, the next day he woke up and he had double vision again. over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe. he states that he called sinai hospital and spoke to a physician who recommended that he come in for evaluation. he was seen by a primary care physician who sent him for an ophthalmologic evaluation. he was seen and referred to the emergency department for an urgent mri to evaluate for possible aneurysm. the patient states that he had a normal mri and was discharged to home.,for the next month, the double vision improved, although he currently still experiences constant diplopia. whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together. he still does not drive. he also is not working due to the double vision. there is no temporal fluctuation to the double vision. more recently, over the past month, he has developed right supraorbital pain. it actually feels like there is pain under his right lid. he denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,there is a neurology consultation in the computer system. dr. x saw the patient on february 2, 2009, when he was in the emergency department. he underwent an mri that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side. mrv was negative and mri of the brain with and without contrast was also negative. he also had an mri of the orbit with and without contrast that was normal. his impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,at the time of the examination, it was documented that he had right lid ptosis. he had left gaze diplopia. the pupils were equal, round, and reactive to light. his neurological examination was otherwise entirely normal. according to dr. x's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil. there was also right medial rectus as well as possibly other extraocular abnormalities. i do not have the official ophthalmologic consultation available to me today.,past medical history: , the patient denies any previous past medical history. he currently does not have a primary care physician as he is uninsured.,medications:, he does not take any medications.,allergies: , he has no known drug allergies.,social history: , the patient lives with his wife. he was an it software developer, but he has been out of work for several months. he smokes less than a pack of cigarettes daily. he denies alcohol or illicit drug use.,family history: , his mother died of a stroke in her 90s. his father had colon cancer. he is unaware of any family members with neurological disorders.,review of systems: , a complete review of systems was obtained and was negative except for as mentioned above. this is documented in the handwritten notes from today's visit.,physical examination:,vital signs: bp 124/76

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

preoperative diagnoses,1. uncontrolled open angle glaucoma, left eye.,2. conjunctival scarring, left eye.,postoperative diagnoses,1. uncontrolled open angle glaucoma, left eye.,2. conjunctival scarring, left eye.,procedures: , short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/ml mitomycin x2 minutes, left eye.,anesthesia: ,retrobulbar block with monitored anesthesia care.,complications: , none.,estimated blood loss:, negligible.,description of procedure:, the patient was brought to the operating suite where the anesthesia team established a peripheral iv as well as monitoring lines. in the preoperative area, the patient received pilocarpine drops. the patient received iv propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% xylocaine plain. approximately 3 ml were given. the operative eye then underwent a betadine prep with respect to the face, lids, lashes, and eye. during the draping process, care was taken to isolate the lashes. a screw type speculum was inserted to maintain patency of lids. a 6-0 vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva. a peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea. all tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis. a 2 mm x 3 mm scleral flap was then outlined with a micro-sharp blade. this was approximately one-half scleral depth in thickness. a crescent blade was then used to dissect forward the clear cornea. hemostasis was again achieved with wet-field cautery. a weck-cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes. the site was then profusely irrigated with balanced salt solution. a paracentesis wound was made temporarily and then the micro-sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed. a kelly-descemet punch was then inserted, and a trabeculectomy was performed. iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using vannas scissors and 0.12 forceps. the iris was then repositioned into the eye and the anterior chamber was inflated with bss. the scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried. the overlying conjunctiva was then closed with a running 8-0 vicryl suture on a bv needle. bss was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage. antibiotic and steroid drops were placed in the eye as was homatropine 5%. the antibiotic consisted of vigamox and the steroid was econopred plus. a patch and shield were placed over the eye after the drape was removed. the patient was taken to the recovery room in good condition. she will be seen in followup in the office tomorrow.

subjective:, the patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. she describes her dizziness as both vertigo and lightheadedness. she does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. she has noticed a few more bruises on her legs. no fever or chills with slight cough. she has had more chest pains but not at present. she does have a little bit of nausea but no vomiting or diarrhea. she complains of some left shoulder tenderness and discomfort. she reports her blood sugar today after lunch was 155.,current medications:, she is currently on her nystatin ointment to her lips q.i.d. p.r.n. she is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. her other meds remain as per the dictation of 07/30/2004 with the exception of her klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,allergies: , sulfa, erythromycin, macrodantin, and tramadol.,objective:,general: she is a well-developed, well-nourished, obese female in no acute distress.,vital signs: her age is 55. temperature: 98.2. blood pressure: 110/70. pulse: 72. weight: 174 pounds.,heent: head was normocephalic. throat: clear. tms clear.,neck: supple without adenopathy.,lungs: clear.,heart: regular rate and rhythm without murmur.,abdomen: soft, nontender without hepatosplenomegaly or mass.,extremities: trace of ankle edema but no calf tenderness x 2 in lower extremities is noted. her shoulders have full range of motion. she has minimal tenderness to the left shoulder anteriorly.,skin: there is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,assessment:,1. headaches.,2. dizziness.,3. atypical chest pains.,4. chronic renal failure.,5. type ii diabetes.,6. myalgias.,7. severe anxiety (affect is still quite anxious.),plan:, i strongly encouraged her to increase her klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m. i sent her to lab for cpk due to her myalgias and pro-time for monitoring her coumadin. recheck in one week. i think her dizziness is multifactorial and due to enlarged part of her anxiety. i do note that she does have a few new bruises on her extremities, which is likely due to her coumadin.

subjective:, this 9-month-old hispanic male comes in today for a 9-month well-child check. they are visiting from texas until the end of april 2004. mom says he has been doing well since last seen. he is up-to-date on his immunizations per her report. she notes that he has developed some bumps on his chest that have been there for about a week. two weeks ago he was diagnosed with left otitis media and was treated with antibiotics. mom says he has been doing fine since then. she has no concerns about him.,past medical history:, significant for term vaginal delivery without complications.,medications: , none.,allergies:, none.,social history:, lives with parents. there is no smoking in the household.,review of systems:, developmentally is appropriate. no fevers. no other rashes. no cough or congestion. no vomiting or diarrhea. eating normally.,objective:, his weight is 16 pounds 9 ounces. height is 26-1/4 inches. head circumference is 44.75 cm. pulse is 124. respirations are 26. temperature is 98.1 degrees. generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,heent: normocephalic, atraumatic. anterior fontanel is soft and flat. tympanic membranes are clear bilaterally. conjunctivae are clear. pupils equal, round and reactive to light. nares without turbinate edema. oropharynx is nonerythematous.,neck: supple, without lymphadenopathy, thyromegaly, carotid bruit, or jvd.,chest: clear to auscultation bilaterally.,cardiovascular: regular rate and rhythm, without murmur.,abdomen: soft, nontender, nondistended, normoactive bowel sounds. no masses or organomegaly to palpation.,gu: normal male external genitalia. uncircumcised penis. bilaterally descended testes. femoral pulses 2/4.,extremities: moves all four extremities equally. minimal tibial torsion.,skin: without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,assessment/plan:,1. well-child check. is doing well. will recommend a followup well-child check at 1 year of age and immunizations at that time. discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with mom. she is given a parenting guide handout.,2. molluscum contagiosum. described the viral etiology of these. told her they are self limited, and we will continue to monitor at this time.,3. left otitis media, resolved. continue to monitor. we will plan on following up in three months if they are still in the area, or p.r.n.

medications: , plavix, atenolol, lipitor, and folic acid.,clinical history: ,this is a 41-year-old male patient who comes in with chest pain, had had a previous mi in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,with the patient at rest, 10.3 mci of cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,procedure and interpretation: ,the patient exercised for a total of 12 minutes on the standard bruce protocol. the peak workload was 12.8 mets. the resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response. the blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90. the test was stopped due to fatigue and leg pain. ekg at rest showed normal sinus rhythm. the peak stress ekg did not reveal any ischemic st-t wave abnormalities. there was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen. at peak, there was no chest pain noted. the test was stopped due to fatigue and left pain. at peak stress, the patient was injected with 30.3 mci of cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,myocardial perfusion imaging:,1. the overall quality of the scan was good.,2. there was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3. the left ventricular cavity appeared normal in size.,4. gated spect images revealed mild septal hypokinesis and mild apical hypokinesis. overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,conclusions:,1. good exercise tolerance.,2. less than adequate cardiac stress. the patient was on beta-blocker therapy.,3. no ekg evidence of stress induced ischemia.,4. no chest pain with stress.,5. mild ventricular bigeminy with exercise.,6. no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7. gated spect images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest.

preoperative diagnoses:,1. oxygen dependency.,2. chronic obstructive pulmonary disease.,postoperative diagnoses:,1. oxygen dependency.,2. chronic obstructive pulmonary disease.,procedures performed:,1. tracheostomy with skin flaps.,2. scoop procedure fasttract.,anesthesia: , total iv anesthesia.,estimated blood loss: , minimal.,complications: ,none.,indications for procedure: , the patient is a 55-year-old caucasian male with a history of chronic obstructive pulmonary disease and o2 dependency of approximately 5 liters nasal cannula at home. the patient with extensive smoking history who presents after risks, complications, and consequences of the scoop fasttract procedure were explained.,procedure:, the patient was brought to operating suite by anesthesia and placed on the operating table in the supine position. after this, the patient was then placed under total iv anesthesia and the operating bed was then placed in reverse trendelenburg. the patient's sternal notch along with cricoid and thyroid cartilages were noted and palpated and a sternal marker was utilized to mark the cricoid cartilage in the sternal notch. the midline was also marked and 1% lidocaine with epinephrine 1:100,000 at approximately 4 cc total was then utilized to localize the neck. after this, the patient was then prepped and draped with hibiclens. a skin incision was then made in the midline with a #15 bard-parker in a vertical fashion. after this, the skin was retracted laterally and a small anterior jugular branch was clamped and cross clamped and tied with #2-0 undyed vicryl ties. further bleeding was controlled with monopolar cauterization and attention was then drawn down on to the strap muscles. the patient's sternohyoid muscle was identified and grasped on either side and the midline raphe was identified. cauterization was then utilized to take down the midline raphe and further dissection was utilized with the skin hook and stat clamps. the anterior aspect of the thyroid isthmus was identified and palpation on the cricoid cartilage was performed. the cricoid cauterization over the cricoid cartilage was obtained with the monopolar cauterization and blunt dissection then was carried along the posterior aspect of the thyroid isthmus. stats were then placed on either side of the thyroid isthmus and the mid portion was bisected with the monopolar cauterization. after this, the patient's anterior trachea was then identified and cleaned with pusher. after this, the cricoid cartilage along the first and second tracheal rings was identified. the cricoid hook was placed and the trachea was brought more anteriorly and superiorly. after this, the patient's head incision was placed below the second tracheal ring with a #15 bard-parker. after this, the patient had a tracheal punch with the scoop fasttract kit to create a small 4 mm punch within the tracheal cartilage. after this, the patient then had a tracheal stent placed within the tracheal punched lumen and the patient was then had the tracheal stent secured to the neck with a vicryl strap. after this, the cricoid hook was removed and the patient then had fio2 on the monitor noted with pulse oximetry of 100%. the patient was then turned back to the anesthesia and transferred to the recovery room in stable condition. the patient tolerated the procedure well and will stay in the hospital for approximately 23 hours. the patient will have the stent guidewire removed with a scoop catheter 11 cm placed.

preoperative diagnosis: , gross hematuria.,postoperative diagnosis: ,gross hematuria.,operations: ,cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,anesthesia: , spinal.,findings: ,significant amount of bladder clots measuring about 150 to 200 ml, two cupful of clots were removed. there was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side. the right ureteral opening was difficult to visualize, the left one was normal.,brief history: , the patient is a 78-year-old male with history of gross hematuria and recurrent utis. the patient had hematuria. cystoscopy revealed atypical biopsy. the patient came in again with gross hematuria. the first biopsy was done about a month ago. the patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria. the options of watchful waiting, removal of the clots and biopsies were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt and pe were discussed. morbidity and mortality of the procedure were discussed. consent was obtained from the daughter-in-law who has the power of attorney in florida.,description of procedure: ,the patient was brought to the or. anesthesia was applied. the patient was placed in the dorsal lithotomy position. the patient was prepped and draped in the usual sterile fashion. the patient had been off of the coumadin for about 4 days and inr had been reversed. the patient has significant amount of clot upon entering the bladder. there was a tight bladder neck contracture. the prostate was not enlarged. using acmi 24-french sheath, using ellick irrigation about 2 cupful of clots were removed. it took about half an hour to just remove the clots. after removing the clots, using 24-french cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected. this was lateral to the left ureteral opening. the base was coagulated for hemostasis. same thing was done at 10 o'clock on the right side where there was some tumor that was visualized. the back wall and the rest of the bladder appeared normal. using 8-french cone-tip catheter, left-sided pyelogram was normal. the right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots. the contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening. a little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation. the patient did have ct with contrast, which showed that the kidneys were normal. at this time, a #24 three-way irrigation was started. the patient was brought to recovery room in stable condition.

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

chief complaint: , chronic low back, left buttock and leg pain.,history of present illness: , this is a pleasant 49-year-old gentleman post lumbar disc replacement from january 2005. unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. he has also tried acupuncture, tens unit, physical therapy, chiropractic treatment and multiple neuropathic medications including elavil, topamax, cymbalta, neurontin, and lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the botox procedure that was done on march 8, 2006 has not given him any relief from his buttock pain. he states that approximately 75% of his pain is in his buttock and leg and 25% in his back. he has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. he rated his pain today as 6/10, describing it is shooting, sharp and aching. it is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. it is constant but variable in degree. it continues to affect activities and sleep at night as well as mood at times. he is currently not satisfied completely with his level of pain relief.,medications: , kadian 30 mg b.i.d., zanaflex one-half to one tablet p.r.n. spasm, and advil p.r.n.,allergies:, no known drug allergies.,review of systems:, complete multisystem review was noted and signed in the chart.,social history:, unchanged from prior visit.,physical examination: , blood pressure 123/87, pulse 89, respirations 18, and weight 220 lbs. he is a well-developed obese male in no acute distress. he is alert and oriented x3, and displays normal mood and affect with no evidence of acute anxiety or depression. he ambulates with normal gait and has normal station. he is able to heel and toe walk. he denies any sensory changes.,assessment & plan: , this is a pleasant 49-year-old with chronic pain plus lumbar disk replacement with radiculitis and myofascial complaints. we discussed treatment options at length and he is willing to undergo a trial of lyrica.,he is sensitive to medications based on his past efforts and is given a prescription for 150 mg that he will start at bedtime. we discussed the up taper schedule and he understands that he will have to be on this for some time before we can decide whether or not it is helpful to him. we also briefly touched on the possibility of a spinal cord stimulator trial if this medication is not helpful to him. he will call me if there are any issues with the new prescription and follow in four weeks for reevaluation.

chief complaint:, left wrist pain.,history of present problem:,

right:,1. mild heterogeneous plaque seen in common carotid artery.,2. moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3. severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%. ,4. peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5. peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,left: , ,1. mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2. moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3. peak systolic velocity is normal in common carotid artery and in the bulb.,4. peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,vertebrals:, antegrade flow seen bilaterally.

reason for visit:, syncope.,history:, the patient is a 75-year-old lady who had a syncopal episode last night. she went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor. she did not have any residual deficit. she had a headache at that time. she denies chest pains or palpitations.,past medical history: , arthritis, first episode of high blood pressure today. she had a normal stress test two years ago.,medications: , her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,social history: , she does not smoke and she does not drink. she lives with her daughter.,physical examination:,general: lady in no distress.,vital signs: blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20. afebrile.,heent: head is normal.,neck: supple.,lungs: clear to auscultation and percussion.,heart: no s3, no s4, and no murmurs.,abdomen: soft.,extremities: lower extremities, no edema.,diagnostic data: , her ekg shows sinus rhythm with nondiagnostic q-waves in the inferior leads.,assessment: ,syncope.,plan: ,she had a ct scan of the brain that was negative today. the blood pressure is high. we will start maxzide. we will do an outpatient holter and carotid doppler study. she has had an echocardiogram along with the stress test before and it was normal. we will do an outpatient followup.

preoperative diagnoses: , malnutrition and dysphagia.,postoperative diagnoses: , malnutrition and dysphagia with two antral polyps and large hiatal hernia.,procedures: , esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,anesthesia: , iv sedation, 1% xylocaine locally.,condition:, stable.,operative note in detail: , after risk of operation was explained to this patient's family, consent was obtained for surgery. the patient was brought to the gi lab. there, she was placed in partial left lateral decubitus position. she was given iv sedation by anesthesia. her abdomen was prepped with alcohol and then betadine. flexible gastroscope was passed down the esophagus, through the stomach into the duodenum. no lesions were noted in the duodenum. there appeared to be a few polyps in the antral area, two in the antrum. actually, one appeared to be almost covering the pylorus. the scope was withdrawn back into the antrum. on retroflexion, we could see a large hiatal hernia. no other lesions were noted. biopsy was taken of one of the polyps. the scope was left in position. anterior abdominal wall was prepped with betadine, 1% xylocaine was injected in the left epigastric area. a small stab incision was made and a large bore angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth. tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall. it was held in position with a dressing and a stent. a connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature. the patient tolerated the procedure well. she was returned to the floor in stable condition.

reason for visit: , overactive bladder with microscopic hematuria.,history of present illness: , the patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. her cystoscopy performed was unremarkable. she continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. no gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. the patient had been previously on ditropan and did not do nearly as well. at this point, what we will try is a different medication. renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,impression: , overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted. she has no other significant findings other than her overactive bladder, which had continued. at this juncture what i would like to do is try a different anticholinergic medication. she has never had any side effects from her medication.,plan: , the patient will discontinue ditropan. we will start sanctura xr and we will follow up as scheduled. otherwise we will continue to follow her urinalysis over the next year or so.

referral indications,1. pacemaker at eri.,2. history av block.,procedures planned and performed:, dual chamber generator replacement.,fluoroscopy time: , 0 minutes.,medication at the time of study,1. ancef 1 g.,2. versed 2 mg.,3. fentanyl 50 mcg.,clinical history: ,the patient is a pleasant patient who presented to the office, recently was found to be at eri and she has been referred for generator replacement.,risks and benefits: , risks, benefits, and alternatives to generator replacement have been discussed with the patient. risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient. the patient agreed both verbally and via written consent.,description of operation: , the patient was transported to the cardiac catheterization laboratory in a fasting state. the region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner. lidocaine 1% (20 ml) was administered to the area of the previous incision. a transverse incision was made through the skin and subcutaneous tissue. hemostasis was achieved with electrocautery. using blunt dissection, pacemaker, and leads were removed from the pocket. leads were disconnected from the pulse generator and interrogated. the pocket was washed with antibiotic impregnated saline. the new pulse generator was obtained and connected securely to the leads and placed back in the pocket. the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using running stitch. sponge and needle counts were correct at the end of the procedure. no acute complications were noted.,device data,1. explanted pulse generator medronic, product # kdr601, serial # abcd1234.,2. new pulse generator medronic, product # addr01, serial # abcd1234.,3. right atrial lead, product # 4068, serial # abcd1234.,4. right atrial lead, product # 4068, serial # abcd1234.,measured intraoperative data,1. right atrial lead impedance 572 ohms. p wave measure 3.7 mv, pacing threshold 1.5 volts at 0.5 msec.,2. right ventricular lead impedance 365 ohms. no r waves to measure, pacing threshold 0.9 volts at 0.5 msec.,conclusions,1. successful dual chamber generator replacement.,2. no acute complications.,plan,1. she will be monitored for 3 hours and then dismissed home.,2. resume all medications. ex-home dismissal instructions.,3. doxycycline 100 mg one p.o. twice daily for 7 days.,4. wound check in 7-10 days.,5. continue followup in device clinic.

procedure performed:, lumbar puncture.,the procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. alternatives were explained. they agreed to proceed with the lumbar puncture. permit was signed and is on the chart. the indication was to rule out toxoplasmosis or any other cns infection. ,description: , the area was prepped and draped in a sterile fashion. lidocaine 1% of 5 ml was applied to the l3-l4 spinal space after the area had been prepped with betadine three times. a 20-gauge spinal needle was then inserted into the l3-l4 space. attempt was successful on the first try and several mls of clear, colorless csf were obtained. the spinal needle was then withdrawn and the area cleaned and dried and a band-aid applied to the clean, dry area.,complications:, none. the patient was resting comfortably and tolerated the procedure well.,estimated blood loss: , none.,disposition: , the patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,the opening pressure was 292, the closing pressure was 190.

history of present illness: ,the patient is a 50-year-old african american female with past medical history significant for hypertension and endstage renal disease, on hemodialysis secondary to endstage renal disease, last hemodialysis was on june 22, 2007. the patient presents with no complaints for cadaveric renal transplant. after appropriate cross match and workup of hla typing of both recipient and cadaveric kidneys, the patient was deemed appropriate for operative intervention and transplantation of kidney.,preoperative diagnosis:, endstage renal disease.,postoperative diagnosis: , endstage renal disease.,procedure:, cadaveric renal transplant to right pelvis.,estimated blood loss: , 400 ml.,fluids: ,one liter of normal saline and one liter of 5% of albumin.,anesthesia: ,general endotracheal.,specimen: ,none.,drain: , none.,complications: , none.,the patient tolerated the procedure without any complication.,procedure in detail: ,the patient was brought to the operating room, prepped and draped in sterile fashion. after adequate anesthesia was achieved, a curvilinear incision was made in the right pelvic fossa approximately 9 cm in length extending from the 1.5 cm medial of the asis down to the suprapubic space. after this was taken down with a #10 blade, electrocautery was used to take down tissue down to the layer of the subcutaneous fat. camper's and scarpa's were dissected with electrocautery. hemostasis was achieved throughout the tissue plains with electrocautery. the external oblique aponeurosis was identified with musculature and was entered with electrocautery. then hemostats were entered in and dissection continued down with electrocautery down through the external internal obliques and the transversalis fascia. additionally, the rectus sheath was entered in a linear fashion. after these planes were entered using electrocautery, the retroperitoneum was dissected free from the transversalis fascia using blunt dissection. after the peritoneum and peritoneal structures were moved medially and superiorly by blunt dissection, the dissection continued down bluntly throughout the tissue planes removing some alveolar tissue over the right iliac artery. upon entering through the transversalis fascia, the epigastric vessels were identified and doubly ligated and tied with #0 silk ties. after the ligation of the epigastric vessels, the peritoneum was bluntly dissected and all peritoneal structures were bluntly dissected to a superior and medial plane. this was done without any complication and without entering the peritoneum grossly. the round ligament was identified and doubly ligated at this time with #0 silk ties as well. the dissection continued down now to layer of the alveolar tissue covering the right iliac artery. this alveolar tissue was cleared using blunt dissection as well as electrocautery. after the external iliac artery was identified, it was cleared circumferentially all the way around and noted to have good flow and had good arterial texture. the right iliac vein was then identified, and this was cleared again using electrocautery and blunt dissection. after the right iliac vein was identified and cleared off all the alveolar tissue, it was circumferentially cleared as well. an additional perforating branch was noted at the inferior pole of the right iliac vein. this was tied with a #0 silk tie and secured. hemostasis was achieved at this time and the tie had adequate control. the dissection continued down and identified all other vital structures in this area. careful preservation of all vital structures was carried out throughout the dissection. at this time, satinsky clamp was placed over the right iliac vein. this was then opened using a #11 blade, approximately 1 cm in length. the heparinized saline was placed and irrigated throughout the inside of the vein, and the kidney was pulled into the abdominal field still covered in its protective socking with the superior pole marked. the renal vein was then elevated and identified in this area. a 5-0 double-ended prolene stitch was used to secure the renal vein, both superiorly and inferiorly, and after appropriately being secured with 5-0 prolene, these were tied down and secured. the renal vein was then anastomosed to the right iliac vein in a circumferential manner in a running fashion until secured at both superior and inferior poles. the dissection then continued down and the iliac artery was then anastomosed to the renal artery at this time using a similar method with 5-0 prolene securing both superior and inferior poles. after such time the 5-0 prolene was run around in a circumferential manner until secured in both superior and inferior poles once again. after this was done and the artery was secured, the satinsky clamp was removed and a bulldog placed over. the flow was then opened on the arterial side and then opened on the venous side to allow for proper flow. the bulldog was then placed back on the renal vein and allowed for the hyperperfusion of the kidney. the kidney pinked up nicely and had a good appearance to it and had appearance of good blood flow. at this time, all satinsky clamps were removed and all bulldog clamps were removed. the dissection then continued down to the layer of the bladder at which time the bladder was identified. appropriate area on the dome the bladder was identified for entry. this was entered using electrocautery and approximately 1 cm length after appropriately sizing and incising of the ureter using the metzenbaum scissors in a linear fashion. before this was done, #0 chromic catgut stitches were placed and secured laterally and inferiorly on the dome of the bladder to elevate the area of the bladder and then the bladder was entered using the electrocautery approximately 1 cm in length. at this time, a renal stent was placed into the ureter and secured superiorly and the stent was then placed into the bladder and secured as well. subsequently, the superior and inferior pole stitches with 5-0 prolene were used to secure the ureter to the bladder. this was then run mucosa-to-mucosa in a circumferential manner until secured in both superior and inferior poles once again. good flow was noted from the ureter at the time of operation. additional vicryl stitches were used to overlay the musculature in a seromuscular stitch over the dome of the bladder and over the ureter itself. at this time, an ethibond stitch was used to make an additional seromuscular closure and rolling of the bladder musculature over the dome and over the anastomosis once again. this was inspected and noted for proper control. irrigation of the bladder revealed that the bladder was appropriately filled and there were no flows and no defects. at this time, the anastomoses were all inspected, hemostasis was achieved and good closure of the anastomosis was noted at this time. the kidney was then placed back into its new position in the right pelvic fossa, and the area was once again inspected for hemostasis which was achieved. a 1-0 prolene stitch was then used for mass closure of the external, internal, and transversalis fascias and musculature in a running fashion from superior to inferior. this was secured and knots were dumped. subsequently, the area was then checked and inspected for hemostasis which was achieved with electrocautery, and the skin was closed with 4-0 running monocryl. the patient tolerated procedure well without evidence of complication, transferred to the dunn icu where he was noted to be stable. dr. a was present and scrubbed through the entire procedure.

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.

prostate brachytherapy - prostate i-125 implantation,this patient will be treated to the prostate with ultrasound-guided i-125 seed implantation. the original consultation and treatment planning will be separately performed. at the time of the implantation, special coordination will be required. stepping ultrasound will be performed and utilized in the pre-planning process. some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process. re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound. modifications will be made in real time to add or subtract needles and seeds as required. this may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,the brachytherapy must be customized to fit the individual's tumor and prostate. attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.

primary diagnosis:, esophageal foreign body, no associated comorbidities are noted.,procedure:, esophagoscopy with removal of foreign body.,cpt code: , 43215.,principal diagnosis:, esophageal foreign body, icd-9 code 935.1.,description of procedure: , under general anesthesia, flexible egd was performed. esophagus was visualized. the quarter was visualized at the aortic knob, was removed with grasper. estimated blood loss 0. intravenous fluids during time of procedure 100 ml. no tissues. no complications. the patient tolerated the procedure well. dr. x pipkin attending pediatric surgeon was present throughout the entire procedure. the patient was transferred from or to pacu in stable condition.

preoperative diagnosis: , congenital myotonic muscular dystrophy with bilateral planovalgus feet.,postoperative diagnosis: , congenital myotonic muscular dystrophy with bilateral planovalgus feet.,procedure: , bilateral crawford subtalar arthrodesis with open achilles z-lengthening and bilateral long-leg cast.,anesthesia: , surgery performed under general anesthesia. the patient received 6 ml of 0.25% marcaine local anesthetic on each side.,tourniquet time: ,tourniquet time was 53 minutes on the left and 45 minutes on the right.,complications: , there were no intraoperative complications.,drains:, none.,specimens: , none.,hardware used: , staple 7/8 inch x1 on each side.,history and physical: ,the patient is a 5-year-4-month-old male who presents for evaluation of feet. he has been having significant feet pain with significant planovalgus deformity. the patient was noted to have flexible vertical talus. it was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and achilles lengthening. this was explained to the mother in detail. this is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. all questions were answered and the mother agreed to the above plan.,procedure note: , the patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered. the patient received ancef preoperatively. bilateral nonsterile tourniquets were placed on each thigh. a bump was placed underneath the left buttock. both the extremities were then prepped and draped in standard surgical fashion. attention was first turned towards the left side. intended incision was marked on the skin. the ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view. the foot was wrapped in esmarch prior to inflation of tourniquet to 200 mmhg. incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint. the sinus tarsi was then identified using a u-shaped flap to tack muscles, and periosteum was retracted distally. once the foot was reduced a steinman pin was used to hold it in position. this position was first checked on the fluoroscopy. the 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction. this was also checked with fluoroscopy. the incision was then extended posteriorly to allow for visualization of the achilles, which was z-lengthened with the release of the lateral distal half. this was sutured using 2-0 ethibond and that was also oversewn. the wound was irrigated with normal saline. the periosteal flap was sutured over the staple using 2-0 vicryl. skin was closed using 2-0 vicryl interrupted and then with 4-0 monocryl. the area was injected with 6 ml of 0.25% marcaine local anesthetic. the wound was cleaned and dried, dressed with steri-strips, xeroform, and 4 x 4s and webril. tourniquet was released after 53 minutes. the exact same procedure was repeated on the right side with no changes or complications. tourniquet time on the right side was 45 minutes. the patient tolerated the procedure well. bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch. the patient was subsequently was taken to recovery in stable condition.,postoperative plan: , the patient will be hospitalized overnight for pain as per parents' request. the patient is to be strict nonweightbearing for at least 6 weeks. he is to follow up in the next 10 days for a check. we will plan of changing to short-leg casts in about 4 weeks postop.

preoperative diagnoses:,1. intrauterine pregnancy at 38 weeks.,2. malpresentation.,postoperative diagnoses:,1. intrauterine pregnancy at 38 weeks.,2. malpresentation.,3. delivery of a viable male neonate.,procedure performed: , primary low transverse cervical cesarean section.,anesthesia: , spinal with astramorph.,estimated blood loss: , 300 cc.,urine output:, 80 cc of clear urine.,fluids: , 2000 cc of crystalloids.,complications: , none.,findings: , a viable male neonate in the left occiput transverse position with apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g. no nuchal cord. no meconium. normal uterus, fallopian tubes, and ovaries.,indications: , this patient is a 21-year-old gravida 3, para 1-0-1-1 caucasian female who presented to labor and delivery in labor. her cervix did make some cervical chains. she did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head. however, on exam unable to delineate the facial structures, but definite fetal malpresentation. the fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring. the contraction pattern was inadequate. it was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended. all the questions were answered.,procedure in detail: , after informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt. prior to this, the spinal anesthesia was administered. the patient was then prepped and draped. a pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel. the fascia was then incised in the midline and extended laterally using mayo scissors. the superior aspect of the rectus fascia was then grasped with ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with mayo scissors. the superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with mayo scissors. the rectus muscle was then separated in the midline. the peritoneum was then identified, tented up with hemostats and entered sharply with metzenbaum scissors. the peritoneum was then gently stretched. the vesicouterine peritoneum was then identified, tented up with an allis and the bladder flap was created bluntly as well as using metzenbaum scissors. the uterus was entered with the second scalpel and large transverse incision. this was then extended in upward and lateral fashion bluntly. the infant was then delivered atraumatically. the nose and mouth were suctioned. the cord was then clamped and cut. the infant was handed off to the awaiting pediatrician. the placenta was then manually extracted. the uterus was exteriorized and cleared of all clots and debris. the uterine incision was then repaired using #0 chromic in a running fashion marking a u stitch. a second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis. the uterus was then returned to the anatomical position. the abdomen and the gutters were cleared of all clots. again, the incision was found to be hemostatic. the rectus muscle was then reapproximated with #2-0 vicryl in a single interrupted stitch. the rectus fascia was then repaired with #0 vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion. this was palpated and the patient was found to be without defect and intact. the skin was then closed with staples. the patient tolerated the procedure well. sponge, lap, and needle counts were correct x2. she will be followed up as an inpatient with dr. x.

preoperative diagnosis (es):, recurrent herniation l4-5 disk with left radiculopathy.,postoperative diagnosis (es):, recurrent herniation l4-5 disk with left radiculopathy.,procedure:, redo l4-5 diskectomy left.,complications:, none.,antibiotic (s),: vancomycin given preoperatively.,anesthesia:, general endotracheal.,estimated blood loss:, 10 ml.,blood replaced:, none.,crystalloid given:, 800 ml.,drain (s):, none.,description of the operation:, the patient was brought to the operating room in supine position. general endotracheal anesthesia was administered. he was turned into the prone position on the operating table and positioned in the modified knee-chest position with andrews frame being used. care was taken to protect pressure points. the back was shaved, scrubbed with betadine scrub, rinsed with alcohol, and prepped with duraprep, and draped in the usual sterile fashion with ioban drape being used. a midline skin incision was made, excising scar from previous surgery. dissection was carried down through the subcutaneous tissue with electrocautery technique. the lumbosacral fascia was split to the left of the spinous process, and subperiosteal dissection of the spinous process and lamina, area of previous laminotomy was identified. cross-table lateral was also made to confirm position. the scar was then loosened from the inferior portion of 4, superior of l5 lamina, and a portion of the lamina was removed. i did identify normal dura. the scar was then lysed from the medial wall. dura and nerve root were identified and protected with nerve root retractor. the bulging disk fragment was still contained under the longitudinal ligament. a rent was made with the penfield and a moderately large fragment was removed. the disk space was then entered with a cruciate cut in the annulus, with additional nuclear material being received. when no other fragments could be removed from the disk space, no other fragments were felt in the central canal under the longitudinal ligament, and a murphy ball could be passed through the foramen without evidence of compression, the decompression was complete. check was made for csf leakage, and no evidence of significant epidural bleeding was present. the wound was irrigated with antibiotic solution. twenty milligrams of depo-medrol was placed over the dura and nerve root. a free fat graft from the subcutaneous tissue was then placed over the dura. closure was obtained with the lumbosacral fascia being reapproximated with #1, running, vicryl suture. subcutaneous closure was obtained in layers with 2-0, running, vicryl suture. skin closure was obtained with 3-0 vicryl subcuticular suture. proxi-strips and sterile dressing was applied. the skin had been infiltrated with 8 ml of 0.5% marcaine with epinephrine.,after a sterile dressing was applied, the patient was turned into the supine position on the waiting recovery room stretcher, brought from under the effects of anesthesia, and taken to the recovery room.

chief complaint: , nausea.,present illness: , the patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. he has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. he feels like he was on it but has not done so. he has overall malaise and a low-grade temperature of 100.3. he denies any prior similar or lesser symptoms. his last normal bowel movement was yesterday. he denies any outright chills or blood per rectum.,past medical history: , significant for hypertension and morbid obesity, now resolved.,past surgical history: , gastric bypass surgery in december 2007.,medications: ,multivitamins and calcium.,allergies: , none known.,family history: ,positive for diabetes mellitus in his father, who is now deceased.,social history: , he denies tobacco or alcohol. he has what sounds like a data entry computer job.,review of systems: ,otherwise negative.,physical examination:, his temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. he is drowsy, but easily arousable and appropriate with conversation. he is oriented to person, place, and situation. he is normocephalic, atraumatic. his sclerae are anicteric. his mucous membranes are somewhat tacky. his neck is supple and symmetric. his respirations are unlabored and clear. he has a regular rate and rhythm. his abdomen is soft. he has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. he otherwise has no organomegaly, masses, or abdominal hernias evident. his extremities are symmetrical with no edema. his posterior tibial pulses are palpable and symmetric. he is grossly nonfocal neurologically.,studies:, his white blood cell count is 8.4 with 79 segs. his hematocrit is 41. his electrolytes are normal. his bilirubin is 2.8. his ast 349, alt 186, alk-phos 138 and lipase is normal at 239.,assessment: , choledocholithiasis, ? cholecystitis.,plan: , he will be admitted and placed on iv antibiotics. we will get an ultrasound this morning. he will need his gallbladder out, probably with intraoperative cholangiogram. hopefully, the stone will pass this way. due to his anatomy, an ercp would prove quite difficult if not impossible unless laparoscopic assisted. dr. x will see him later this morning and discuss the plan further. the patient understands.

preoperative diagnosis:, right buccal space infection and abscess tooth #t.,postoperative diagnosis: , right buccal space infection and abscess tooth #t.,procedure:, extraction of tooth #t and incision and drainage (i&d) of right buccal space infection.,anesthesia:, general, oral endotracheal tube.,complications: , none.,specimens:, aerobic and anaerobic cultures were sent.,iv fluid: , 150 ml.,estimated blood loss:, 10 ml.,procedure: , the patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure. gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located. the abscess cavity was aspirated using a 5 ml syringe with an 18-gauge needle. approximately 1 ml of purulent material was aspirated that was placed on aerobic and anaerobic cultures. culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,the area in the buccal vestibule was then opened with approximately 1-cm incision. blunt dissection was then used to open up the abscess cavity and explore the abscess cavity. a small amount of additional purulence was drained from it, approximately 1 ml and at this point, tooth #t was extracted by forceps extraction. periosteal elevator was used to explore the area near the extraction site. this was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site. no drain was placed. upon completion of the procedure, the throat pack was removed. the pharynx was suctioned. the stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.

history:, patient is a 54-year-old male admitted with diagnosis of cva with right hemiparesis.,patient is currently living in abc with his son as this was closer his to his job. at discharge, he will live with his spouse in a new job. the home is single level with no steps.,prior to admission, his wife reports that he was independent with all activities. he was working full time for an oil company.,past medical history includes hypertension and diabetes, mental status, and dysphagia.,ability to follow instruction/rules: not able to identify cognitive status as of yet.,communication skills: , no initiation of conversation. he answered 1 yes/no question.,physical status:, fall/safety. aspiration precautions.,endurance: ball activities 4 to 5 minutes. restorator 25 minutes. standing and rolling type of 3 minutes.,leisure lifestyle:,level of participation/activities involved in: reading and housework.,information obtained:, interview, observation, and chart review.,treatment plan: ,treatment plan and goals were discussed with patient along with identification of results of functional assessment of characteristics for therapeutic recreation identifying need for intervention in the following problem areas: patient scored 10/11 in physical domain due to decreased endurance. he scored 11/11 in the cognitive and social domain.,patient will attend 1 session per day focusing on: endurance activities.,patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,goals:,patient goals: , not able to identify, but cooperative with all activities. he answered yes that he enjoyed the restorator.,short term goals/one week goals:,1. patient to increase tolerance for ball activities to 7 minutes.,2. patient provided to use the restorator as he enjoys and it is good for endurance.,long term goals:, patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,patient has concurred with the above treatment planning goals.

preoperative diagnosis: , left carpal tunnel syndrome.,postoperative diagnosis:, left carpal tunnel syndrome.,operative procedure performed:, left carpal tunnel release.,findings:, showed severe compression of the median nerve on the left at the wrist.,specimens: ,none.,fluids:, 500 ml of crystalloids.,urine output:, no foley catheter.,complications: , none.,anesthesia: , general through a laryngeal mask.,estimated blood loss: , none.,condition: , resuscitated with stable vital signs.,indication for the operation: , this is a case of a very pleasant 65-year-old forensic pathologist who i previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at c5-6 and c6-7 with spinal instrumentation. at the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now. operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia. there is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection. he understood this risk and agreed to have the procedure performed.,description of the procedure: , the patient was brought to the operating room, awake, alert, not in any form of distress. after smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table. the left upper extremity was then prepped with betadine soap and antiseptic solution. after sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmhg. clamp time approximately 30 minutes. an incision was then made right in the mid palm area between the thenar and hypothenar eminence. meticulous hemostasis of any bleeders were done. the fat was identified. the palmar aponeurosis was identified and cut and this was traced down to the wrist. there was severe compression of the median nerve. additional removal of the aponeurosis was performed to allow for further decompression. after this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using prolene 4-0 as interrupted vertical mattress stitches. dressing was applied. the patient was brought to the recovery.

chief complaint:, newly diagnosed mantle cell lymphoma.,history of present illness: , the patient is a 47-year-old woman who presented with abdominal pain in september 2006. on chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone. symptoms improved temporarily, but did not completely resolve. by the end of september, her pain had worsened and she was seen in the emergency room at abc. chest x-ray was compatible with pleurisy and she was treated with percocet. few days later, she was seen and given a prescription for ultram because percocet was causing nausea. eventually, she was seen by dr. x and noted to have splenomegaly. repeat ultrasound was done and showed the spleen enlarged at 19 cm. in retrospect, this was not changed in comparison to an ultrasound that was done in september. she underwent positron emission tomography (pet) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,the patient underwent lymph node biopsy on the right neck on 10/27/2006. pathology is consistent with mantle cell lymphoma.,on 10/31/2006, she had a bone marrow biopsy. this does show involvement of bone marrow with lymphoma.,she was noted to have circulating lymphoma cells on peripheral smear as well.,although cbc was normal, mcv was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,allergies:, none.,medications: ,1. estradiol/prometrium. ,2. ultram p.r.n. ,3. baby aspirin. ,4. lunesta for sleep. ,5. she has been started on iron supplements.,past medical history: ,1. tubal ligation in 1986.,2. possible cyst removed from the left neck in 1991.,3. tonsillectomy.,4. migraines, which are rare.,social history: , she does not smoke cigarettes and drinks alcohol only occasionally. she is married and has two children, ages 24 and 20. she works as a project administrator.,family history: ,father is deceased. he had emphysema and colon cancer at age 68. mother has arrhythmia and hypertension. her sister has hypertension and her brother is healthy.,physical examination: ,general: she is in no acute distress.,vital signs: her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,heent: the oropharynx is benign.,skin: the skin is warm and dry and shows no jaundice.,neck: there is shotty adenopathy in the neck.,cardiac: regular rate without murmur.,lungs: clear to auscultation bilaterally.,abdomen: soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,extremities: no peripheral edema is noted.,laboratory data: , cbc and chemistry panel are pending. cbc was normal last week. pt/inr was normal as well.,impression:, newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy. she will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone. toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc. written materials were provided to her last week.,plan: , plan will be to add rituxan a little later in her course because she has circulating lymphoma cells. she will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,plan will be to have her evaluated for bone marrow transplant in first remission. i will have dr. y see her while she is in the hospital.,the patient is anxious, and will be given ativan as needed. we will discontinue aspirin for now, but continue estradiol/prometrium.,iron deficiency will be treated with oral iron supplements and we will follow her counts. she may well have gastrointestinal (gi) involvement, which is not uncommon with mantle cell lymphoma. after she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.

preoperative diagnosis: , bilateral undescended testes.,postoperative diagnosis: , bilateral undescended testes, bilateral intraabdominal testes.,procedure: , examination under anesthesia and laparoscopic right orchiopexy.,estimated blood loss:, less than 5 ml.,fluids received: ,110 ml of crystalloid.,intraoperative findings: , atrophic bilateral testes, right is larger than left. the left had atrophic or dysplastic vas and epididymis.,tubes and drains: , no tubes or drains were used.,indications for operation: ,the patient is a 7-1/2-month-old boy with bilateral nonpalpable testes. plan is for exploration, possible orchiopexy.,description of operation: ,the patient was taken to the operating room where surgical consent, operative site, and patient identification were verified. once he was anesthetized, he was then palpated and again both testes were nonpalpable. because of this, a laparoscopic approach was then elected. we then sterilely prepped and draped the patient, put an 8-french feeding tube in the urethra, attached to bulb grenade for drainage. we then made an infraumbilical incision with a 15-blade knife and then further extended with electrocautery and with curved mosquito clamps down to the rectus fascia where we made stay sutures of 3-0 monocryl on the anterior and posterior sheaths and then opened up the fascia with the curved metzenbaum scissors. once we got into the peritoneum, we placed a 5-mm port with 0-degree short lens. insufflation was then done with carbon dioxide up to 10 to 12 mmhg. we then evaluated. there was no bleeding noted. he had a closed ring on the left with a small testis that was evaluated and found to have short vessels as well as atrophic or dysplastic vas, which was barely visualized. the right side was also intraabdominal, but slightly larger, had better vessels, had much more recognizable vas, and it was closer to the internal ring. so, we elected to do an orchiopexy on the right side. using the laparoscopic 3- and 5-mm dissecting scissors, we then opened up the window at the internal ring through the peritoneal tissue, then dissected it medially and laterally along the line of the vas and along the line of the vessels up towards the kidney, mid way up the abdomen, and across towards the bladder for the vas. we then used the maryland dissector to gently tease this tissue once it was incised. the gubernaculum was then divided with electrocautery and the laparoscopic scissors. we were able to dissect with the hook dissector in addition to the scissors the peritoneal shunts with the vessels and the vas to the point where we could actually stretch and bring the testis across to the other side, left side of the ring. we then made a curvilinear incision on the upper aspect of the scrotum on the right with a 15-blade knife and extended down the subcutaneous tissue with electrocautery. we used the curved tenotomy scissors to make a subdartos pouch. using a mosquito clamp, we were able to go in through the previous internal ring opening, grasped the testis, and then pulled it through in a proper orientation. using the hook electrode, we were able to dissect some more of the internal ring tissue to relax the vessels and the vas, so there was no much traction. using 2 stay sutures of 4-0 chromic, we tacked the testis to the base of scrotum into the middle portion of the testis. we then closed the upper aspect of the subdartos pouch with a 4-0 chromic and then closed the subdartos pouch and the skin with subcutaneous 4-0 chromic. we again evaluated the left side and found again that the vessels were quite short. the testis was more atrophic, and the vas was virtually nonexistent. we will go back at a later date to try to bring this down, but it will be quite difficult and has a higher risk for atrophy because of the tissue that is present. we then removed the ports, closed the fascial defects with figure-of-eight suture of 3-0 monocryl, closed the infraumbilical incision with two monocryl stay sutures to close the fascial sheath, and then used 4-0 rapide to close the skin defects, and then using dermabond tissue adhesives, we covered all incisions. at the end of the procedure, the right testis was well descended within the scrotum, and the feeding tube was removed. the patient had iv toradol and was in stable condition upon transfer to recovery room.

xyz, d.c.,re: abc,dear dr. xyz:,i had the pleasure of seeing your patient, abc, today mm/dd/yyyy in consultation. he is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on mm/dd/yyyy, where he was the driver of an automobile, which was struck on the front passenger's side. the patient sustained impact injuries to his neck and lower back. there was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures. he was taken to hospital, x-rays were taken, apparently which were negative and he was released.,at the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg. he has had no difficulty with bowel or bladder function. he does experience intermittent headaches associated with his neck pain with no other associated symptoms.,past health:, he was injured in a prior motor vehicle accident on mm/dd/yyyy. at the time of his most recent injuries, he was completely symptom free and under no active therapy. there is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,social history: , he denies tobacco or alcohol consumption.,allergies: , no known drug allergies.,current medications: ,none.,family history: , otherwise noncontributory.,functional inquiry: , otherwise noncontributory.,review of diagnostic studies:, includes an mri scan of the cervical spine dated mm/dd/yyyy which showed evidence for disc bulging at the c6-c7 level. mri scan of the lumbar spine on mm/dd/yyyy, showed evidence of a disc herniation at the l1-l2 level as well as a disc protrusion at the l2-l3 level with disc herniations at the l3-l4 and l4-l5 level and disc protrusion at the l5-s1 level.,physical examination: , reveals an alert and oriented male with normal language function. vital signs: blood pressure was 105/68 in the left arm sitting. heart rate was 70 and regular. height was 5 feet 8 inches. weight was 182 pounds. cranial nerve evaluation was unremarkable. pupils were equal and reactive. funduscopic evaluation was clear. there was no evidence for nystagmus. there was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature. straight leg raising was limited to 45 degrees on the right and 90 degrees on the left. motor strength was 5/5 on the mrc scale. reflexes were 2+ symmetrical and active. no pathological responses were noted. sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity. cerebellar function was normal. there was normal station and gait. chest and cardiovascular evaluations were unremarkable. heart sounds were normal. there were no extra sounds or murmurs. palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,clinical impression: , reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on mm/dd/yyyy. in view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, i have scheduled him for an emg study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms. palpable trigger points were noted on today's evaluation. he is suffering from ongoing myofascitis. his treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time. i have encouraged him to continue with his ongoing treatment program under your care and supervision. i will be following him in two weeks' time. once again, thank you kindly for allowing me to participate in this patient's care and management.,yours sincerely,,

admission diagnosis: , symptomatic cholelithiasis.,discharge diagnosis:, symptomatic cholelithiasis.,service: , surgery.,consults:, none.,history of present illness: , ms. abc is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. she was afebrile. she was taken by dr. x to the operating room.,hospital course: , the patient underwent a procedure. she tolerated without difficulty. she had her pain controlled with p.o. pain medicine. she was afebrile. she is tolerating liquid diet. it was felt that the patient is stable for discharge. she did complain of bladder spasms when she urinated and she did say that she has a history of chronic utis. we will check a ua and urine culture prior to discharge. i will give her prescription for ciprofloxacin that she can take for 3 days presumptively and i have discharged her home with omeprazole and colace to take over-the-counter for constipation and we will send her home with percocet for pain. her labs were within normal limits. she did have an elevated white blood cell count, but i believe this is just leukemoid reaction, but she is afebrile, and if she does have uti, may also be related. her labs in terms of her bilirubin were within normal limits. her lfts were slightly elevated, i do believe this is related to the cautery used on the liver bed. they were 51 and 83 for the ast and alt respectively. i feel that she looks good for discharge.,discharge instructions: , clear liquid diet x48 hours and she can return to her medifast, she may shower. she needs to keep her wound clean and dry. she is not to engage in any heavy lifting greater than 10 pounds x2 weeks. no driving for 1 to 2 weeks. she must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility. she can resume her medications per med rec sheets.,discharge medications: , as previously mentioned.,followup:, we will follow up on both urinalysis and cultures. she is instructed to follow up with dr. x in 2 weeks. she needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.

reason for consultation: , congestive heart failure.,history of present illness: , the patient is a 75-year-old gentleman presented through the emergency room. symptoms are of shortness of breath, fatigue, and tiredness. main complaints are right-sided and abdominal pain. initial blood test in the emergency room showed elevated bnp suggestive of congestive heart failure. given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation. incidentally, his x-ray confirms pneumonia.,coronary risk factors: , history of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,family history: , positive for coronary artery disease.,past surgical history: , the patient denies any major surgeries.,medications: ,aspirin, coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,allergies: , none reported.,personal history:, married, active smoker, does not consume alcohol. no history of recreational drug use.,past medical history: , hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, copd, and presentation as above. the patient is on anticoagulation on coumadin, the patient does not recall the reason.,review of systems:,constitutional: weakness, fatigue, and tiredness.,heent: history of blurry vision and hearing impaired. no glaucoma.,cardiovascular: shortness of breath, congestive heart failure, and arrhythmia. prior history of chest pain.,respiratory: bronchitis and pneumonia. no valley fever.,gastrointestinal: no nausea, vomiting, hematemesis, melena, or abdominal pain.,urological: no frequency or urgency.,musculoskeletal: no arthritis or muscle weakness.,skin: non-significant.,neurological: no tia. no cva or seizure disorder.,endocrine: non-significant.,hematological: non-significant.,psychological: anxiety. no depression.,physical examination:,vital signs: pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,heent: atraumatic and normocephalic.,neck: supple. neck veins flat.,lungs: air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,heart: pmi displaced. s1 and s2, regular. systolic murmur.,abdomen: soft and nontender.,extremities: trace edema of the ankle. pulses are feebly palpable. clubbing plus. no cyanosis.,cns: grossly intact.,musculoskeletal: arthritic changes.,psychological: normal affect.,laboratory and diagnostic data: , ekg shows sinus bradycardia, intraventricular conduction defect. nonspecific st-t changes.,laboratories noted with h&h 10/32 and white count of 7. inr 1.8. bun and creatinine within normal limits. cardiac enzyme profile first set 0.04, bnp of 10,000.,nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,impression: , the patient is a 75-year-old gentleman admitted for:

preoperative diagnosis: ,right ureteropelvic junction obstruction.,postoperative diagnoses:,1. right ureteropelvic junction obstruction.,2. severe intraabdominal adhesions.,3. retroperitoneal fibrosis.,procedures performed:,1. laparoscopic lysis of adhesions.,2. attempted laparoscopic pyeloplasty.,3. open laparoscopic pyeloplasty.,anesthesia:, general.,indication for procedure: ,this is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-j ureteral stent. the patient presents for laparoscopic pyeloplasty.,procedure: , after informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic. the patient was sterilely prepped and draped in the supine fashion after building up the right side of the or table to aid in the patient's positioning for bowel retraction. hassan technique was performed for the initial trocar placement in the periumbilical region. abdominal insufflation was performed. there were significant adhesions noted. a second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular. after adhesions were taken down, the ascending colon was mobilized by incising the white line of toldt and mobilizing this medially. the kidney was able to be palpated within gerota's fascia. the psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter. the uterus was grasped with a babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction. the renal pelvis was also identified and dissected free. there was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes. we were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open. an incision was made from the right upper quadrant port extending towards the midline. this was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum. a bookwalter retractor was placed. the renal pelvis and the ureter were again identified. fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and bovie cautery. the tissue was sent down to pathology for analysis. please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted. ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place. the renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue. at this point, the indwelling double-j ureteral stent was removed. at this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 vicryl suture was placed. this was brought up to the deepened portion of the pyelotomy and cystic structures were approximated. the back wall of the ureteropelvic anastomosis was then approximated with running #4-0 vicryl suture. at this point, a double-j stent was placed with a guidewire down into the bladder. the anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running vicryl suture. renal sinus fat was then placed around the anastomosis and sutured in place. please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue. this was repaired with horizontal mattress sutures #2-0 vicryl. floseal was placed over this and the renal capsule was placed over this. a good hemostasis was noted. a #10 blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis. the initial trocar incision was closed with #0 vicryl suture. the abdominal incision was also then closed with running #0 vicryl suture incorporating all layers of muscle and fascia. the scarpa's fascia was then closed with interrupted #3-0 vicryl suture. the skin edges were then closed with staples. please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator. we placed the patient on iv antibiotics and pain medications. we will obtain kub and x-rays for stent placement. further recommendations to follow.

preoperative diagnosis: , microscopic hematuria.,postoperative diagnosis:, microscopic hematuria with lateral lobe obstruction, mild.,procedure performed: , flexible cystoscopy.,complications: , none.,condition: , stable.,procedure: , the patient was placed in the supine position and sterilely prepped and draped in the usual fashion. after 2% lidocaine was instilled, the anterior urethra is normal. the prostatic urethra reveals mild lateral lobe obstruction. there are no bladder tumors noted.,impression:, the patient has some mild benign prostatic hyperplasia. at this point in time, we will continue with conservative observation.,plan: , the patient will follow up as needed.

indications: ,chest pain, hypertension, type ii diabetes mellitus.,procedure done:, dobutamine myoview stress test.,stress ecg results:, the patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes. atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion. the resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, qs pattern in leads v1 and v2, and diffuse nonspecific t wave abnormality. the heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate. the blood pressure increased from 130/80 to 160/70. a maximum of 1 mm j-junctional depression was seen with fast up sloping st segments during dobutamine infusion. no ischemic st segment changes were seen during dobutamine infusion or during the recovery process.,myocardial perfusion imaging:, resting myocardial perfusion spect imaging was carried out with 10.9 mci of tc-99m myoview. dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mci of tc-99m myoview. the lung heart ratio is 0.36. myocardial perfusion images were normal both at rest and with stress. gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,conclusions:,1. stress test is negative for dobutamine-induced myocardial ischemia.,2. normal left ventricular size, regional wall motion, and ejection fraction.

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

preoperative diagnoses,1. recurrent acute otitis media, bilateral middle ear effusions.,2. chronic rhinitis.,3. recurrent adenoiditis with adenoid hypertrophy.,postoperative diagnoses,1. recurrent acute otitis media, bilateral middle ear effusions.,2. chronic rhinitis.,3. recurrent adenoiditis with adenoid hypertrophy.,final diagnoses,1. recurrent acute otitis media, bilateral middle ear effusions.,2. chronic rhinitis.,3. recurrent adenoiditis with adenoid hypertrophy.,4. acute and chronic adenoiditis.,operations performed,1. bilateral myringotomies.,2. placement of ventilating tubes.,3. nasal endoscopy.,4. adenoidectomy.,description of operations: , the patient was brought to the operating room, endotracheal intubation carried out by dr. x. both sides of the patient's nose were then sprayed with afrin. ears were inspected then with the operating microscope. the anterior inferior quadrant myringotomy incisions were performed. then, a modest amount of serous and a trace of mucoid material encountered that was evacuated. the middle ear mucosa looked remarkably clean. armstrong tubes were inserted. ciprodex drops were instilled. ciprodex will be planned for two postoperative days as well. nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products. the adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken. additional adenoid tissue was shaved backwards with the radenoid shaver. electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished. the patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken. that remaining material was resected, guided by the nasal endoscope using the radenoid shaver to remove the material and flush with the posterior nasopharynx. electrocautery again used to establish hemostasis. bleeding was trivial. extensive irrigation accomplished. no additional bleeding was evident. the patient was awakened, extubated, taken to the recovery room in a stable condition. discharge anticipated later in the day on augmentin 400 mg twice daily, lortab or tylenol p.r.n. for pain. office recheck would be anticipated if stable and doing well in approximately two weeks. parents were instructed to call, however, regarding the outcome of the culture on monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.

identifying data:, this is a 40-year-old male seen today for a 90-day revocation admission. he had been reported by his case manager as being noncompliant with medications, refusing oral or im medications, became agitated, had to be taken to abcd for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time. he has a psychiatric history of schizophrenia, was previously admitted here at xyz on 12/19/2009, had another voluntary admission in abcd in 1998.,medications: , listed as invega and risperdal.,allergies: , none known to medications.,past medical history: ,the only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. the patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,family history: , listed as unknown in the chart as far as other psychiatric illnesses. the patient himself states that his parents are deceased and that he raised himself in the philippines.,social history:, he immigrated to this country in 1984, although he lists himself as having a green card still at this time. he states he lives on his own. he is a single male with no history of marriage or children and that he had high school education. his recreational drug use in the chart indicates that he has had a history of methamphetamines. the patient denies this at this time. he also denies current alcohol use. he does smoke. he is unable to tell me of any pcp. he is in counseling service with his case manager being xyz.,legal history: , he had an assault in december 2009, which led to his previous detention. it is unknown whether he is under legal constraints at this time.,objective findings: ,vital signs: , blood pressure is 125/75. his weight is 197 with height 5 feet 4 inches.,general:, he is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications. he does not endorse any voices at this time.,heent: , his head exam is normal with normal scalp. heent is unremarkable. pupils equal and reactive to light and accommodation. tms are normal.,neck:, unremarkable with no masses or tenderness.,cardiovascular:, normal s1 and s2. no murmurs.,lungs:, clear.,abdomen: ,negative with no scars.,gu: ,not done.,rectal:, not done.,derm:, he does have a scarring of acne lesions, both face and back.,extremities:, otherwise negative.,neurologic: , cranial nerves ii through x normal. reflexes are normal and gait is unremarkable.,laboratory data: , his labs done at abcd showed his cmp to be normal with an elevated white count of 17.2. chest x-ray was indicated as being done and normal as was a ua and he did apparently receive hydration in the hospital with iv fluids.,assessment: , history of hyperlipidemia with elevated triglycerides. we will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated.