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

preoperative diagnoses: ,1. left back skin nevus 2 cm.,2. right mid back skin nevus 1 cm.,3. right shoulder skin nevus 2.5 cm.,4. actinic keratosis left lateral nasal skin 2.5 cm.,postoperative diagnoses: ,1. left back skin nevus 2 cm.,2. right mid back skin nevus 1 cm.,3. right shoulder skin nevus 2.5 cm.,4. actinic keratosis, left lateral nasal skin, 2.5 cm.,pathology: ,pending.,title of procedures: ,1. excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2. excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3. excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4. trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,anesthesia: , xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 ml.,blood loss: , minimal.,complications:, none.,procedure:, consent was obtained. the areas were prepped and draped and localized in the usual manner. first attention was drawn to the left back. an elliptical incision was made with a 15-blade scalpel. the skin ellipse was then grasped with a bishop forceps and curved iris scissors were used to dissect the skin ellipse. after dissection, the skin was undermined. radiofrequency cautery was used for hemostasis, and using a 5-0 undyed vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,next, attention was drawn to the mid back. the skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a bishop forceps and excised with curved iris scissors. afterwards, the skin was approximated using 4-0 nylon interrupted sutures. next, attention was drawn to the shoulder lesion. it was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,next, the skin was grasped with a small bishop forceps and curved iris scissors were used to dissect the skin ellipse and removed the skin. the skin was undermined with the curved iris scissors and then radio frequency treatment was used for hemostasis.,next, subcuticular plain was closed with 5-0 undyed vicryl interrupted suture. skin was closed with 4-0 nylon suture, interrupted. lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed. please refer to separate operative report for details. the patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.

subjective:, this is a 38-year-old female who comes for dietary consultation for gestational diabetes. patient reports that she is scared to eat because of its impact on her blood sugars. she is actually trying not to eat while she is working third shift at wal-mart. historically however, she likes to eat out with a high frequency. she enjoys eating rice as part of her meals. she is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at wal-mart and has young children at home. she sleeps two to four hours at a time throughout the day. she has been testing for ketones first thing in the morning when she gets home from work.,objective:, today's weight: 155.5 pounds. weight from 10/07/04 was 156.7 pounds. a diet history was obtained. blood sugar records for the last three days reveal the following: fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88. i instructed the patient on dietary guidelines for gestational diabetes. the lily guide for meal planning was provided and reviewed. additional information on gestational diabetes was applied. a sample 2000-calorie meal plan was provided with a carbohydrate budget established.,assessment:, patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day. her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day. her diet history reveals that she has somewhat irregular eating patterns. in the last 24 hours when she was working at wal-mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m. we discussed the need for small frequent eating. we identified carbohydrate as the food source that contributes to the blood glucose response. we identified carbohydrate sources in the food supply, recognizing that they are all good for her. the only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars. in regard to use of her traditional foods of rice, i pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice. we discussed the need for moderating the portion of carbohydrates consumed at one given time. emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake. her weight loss was discouraged. patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,plan:, the meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan. the meal plan was devised to distribute her carbohydrates more evenly throughout the day. the meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time. the meal plan is as follows: breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings. recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep. encouraged adequate rest. also recommend adequate calories to sustain weight gain of one-half to one pound per week. if the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly. this was a one-hour consultation. i provided my name and number should additional needs arise.

subsequently, the patient developed a moderately severe depression. she was tried on various medications, which caused sweating, nightmares and perhaps other side effects. she was finally put on effexor 25 mg two tablets h.s. and trazodone 100 mg h.s., and has done fairly well, although she still has significant depression.,her daughter brought her in today to be sure that she does not have dementia. there is no history of memory loss. there is no history of focal neurologic symptoms or significant headaches.,the patient's complaints, according to the daughter, include not wanted to go out in public, shamed regarding her appearance (25-pound weight loss over the past year), eating poorly, not doing things unless asked, hiding food to prevent having to eat it, nervousness, and not taking a shower. she has no focal neurologic deficits. she does complain of constipation. she has severe sleep maintenance insomnia and often sleeps only 2 hours before awakening frequently for the rest of the night.,the patient was apparently visiting her daughter in northern california in december 2003. she was taken to her daughter's primary care physician. she underwent vitamin b12 level, rpr, t4 and tsh, all of which were normal.,on 05/15/04, the patient underwent mri scan of the brain. i reviewed the scan in the office today. this shows moderate cortical and central atrophy and also shows mild-to-moderate deep white matter ischemic changes.,past medical history: , the patient has generally been in reasonably good physical health. she did have a "nervous breakdown" in 1975 after the death of her husband. she was hospitalized for several weeks and was treated with ect. this occurred while she was living in korea.,she does not smoke or drink alcoholic beverages. she has had no prior surgeries. there is a past history of hypertension, but this is no longer present.,family history: , negative for dementia. her mother died of a stroke at the age of 62.,physical examination:,vital signs: blood pressure 128/80, pulse 84, temperature 97.4 f, and weight 105 lbs (dressed).,general: well-developed, well-nourished korean female in no acute distress.,head: normocephalic, without evidence of trauma or bruits.,neck: supple, with full range of motion. no spasm or tenderness. carotid pulsations are of normal volume and contour bilaterally without bruits. no thyromegaly or adenopathy.,extremities: no clubbing, cyanosis, edema, or deformity. range of motion full throughout.,neurological examination:,mental status: the patient is awake, alert and oriented to time, place, and person and generally appropriate. she exhibits mild psychomotor retardation and has a flat or depressed affect. she knows the current president of korea and the current president of the united states. she can recall 3 out of 3 objects after 5 minutes. calculations are performed fairly well with occasional errors. there is no right-left confusion, finger agnosia, dysnomia or aphasia.,cranial nerves:,ii:

preoperative diagnosis: , morbid obesity.,postoperative diagnosis: ,morbid obesity.,procedure: , laparoscopic antecolic antegastric roux-en-y gastric bypass with eea anastomosis.,anesthesia: , general with endotracheal intubation.,indication for procedure: , this is a 30-year-old female, who has been overweight for many years. she has tried many different diets, but is unsuccessful. she has been to our bariatric surgery seminar, received some handouts, and signed the consent. the risks and benefits of the procedure have been explained to the patient.,procedure in detail: ,the patient was taken to the operating room and placed supine on the operating room table. all pressure points were carefully padded. she was given general anesthesia with endotracheal intubation. scd stockings were placed on both legs. foley catheter was placed for bladder decompression. the abdomen was then prepped and draped in standard sterile surgical fashion. marcaine was then injected through umbilicus. a small incision was made. a veress needle was introduced into the abdomen. co2 insufflation was done to a maximum pressure of 15 mmhg. a 12-mm versastep port was placed through the umbilicus. i then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side. i placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, i placed a 12-mm versastep port. on the left side, just anterior to the midaxillary line and just subcostal, i placed a 5-mm port. a few centimeters below and medial to that, i placed a 15-mm port. i began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of treitz. i ran the small bowel down approximately 40 cm and divided the small bowel with a white load gia stapler. i then divided the mesentery all the way down to the base of the mesentery with a ligasure device. i then ran the distal bowel down, approximately 100 cm, and at 100 cm, i made a hole at the antimesenteric portion of the roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and i passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis. i reapproximated the edges of the defect. i lifted it up and stapled across it with another white load stapler. i then closed the mesenteric defect with interrupted surgidac sutures. i divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic. i then put the patient in reverse trendelenburg. i placed a liver retractor, identified, and dissected the angle of his. i then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space. i fired transversely across the stomach with a 45 blue load stapler. i then used two fires of the 60 blue load with seamguard to go up into my angle of his, thereby creating my gastric pouch. i then made a hole at the base of the gastric pouch and had anesthesia remove the bougie and place the og tube connected to the anvil. i pulled the anvil into place, and i then opened up my 15-mm port site and passed my eea stapler. i passed that in the end of my roux limb and had the spike come out antimesenteric. i joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my roux limb with a white load gi stapler, and removed it with an endocatch bag. i put some additional 2-0 vicryl sutures in the anastomosis for further security. i then placed a bowel clamp across the bowel. i went above and passed an egd scope into the mouth down to the esophagus and into the gastric pouch. i distended gastric pouch with air. there was no air leak seen. i could pass the scope easily through the anastomosis. there was no bleeding seen through the scope. we closed the 15-mm port site with interrupted 0 vicryl suture utilizing carter-thomason. i copiously irrigated out that incision with about 2 l of saline. i then closed the skin of all incisions with running monocryl. sponge, instrument, and needle counts were correct at the end of the case. the patient tolerated the procedure well without any complications.

discharge diagnoses:, brca-2 mutation. ,history of present illness: ,the patient is a 59-year-old with a brca-2 mutation. her sister died of breast cancer at age 32 and her daughter had breast cancer at age 27.,physical examination: ,the chest was clear. the abdomen was nontender. pelvic examination shows no masses. no heart murmur. ,hospital course: ,the patient underwent surgery on the day of admission. in the postoperative course she was afebrile and unremarkable. the patient regained bowel function and was discharged on the morning of the fourth postoperative day.,operations and procedures: , total abdominal hysterectomy/bilateral salpingo-oophorectomy with resection of ovarian fossa peritoneum en bloc on july 25, 2006.,pathology: , a 105-gram uterus without dysplasia or cancer.,condition on discharge: , stable.,plan: ,the patient will remain at rest initially with progressive ambulation after. she will avoid lifting, driving or intercourse. she will call me if any fevers, drainage, bleeding, or pain. follow up in my office in four weeks. family history, social history, psychosocial needs per the social worker.,discharge medications: , percocet 5 #40 one every 3 hours p.r.n. pain.

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.

admission diagnosis: , upper respiratory illness with apnea, possible pertussis.,discharge diagnosis: , upper respiratory illness with apnea, possible pertussis.,complications: , none.,operations: , none,brief history and physical: , this is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission. this involved cough, post-tussive emesis, questionable fever, but only 99.7. their usual doctor prescribed amoxicillin over the phone. the coughing persisted and worsened. she went to the er, where sats were normal at baseline, but dropped into the 80s with coughing spells. they did witness some apnea. they gave some rocephin, did some labs, and the patient was transferred to hospital.,physical examination: , on admission, general: well-developed, well-nourished baby in no apparent distress. heent: there was some nasal discharge. remainder of the heent was normal. lung: had few rhonchi. no retractions. no significant coughing or apnea during the admission physical. abdomen: benign. extremities: were without any cyanosis.,significant labs and x-rays: ,she had a cbc done garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal bmp. an x-ray was done and i do not have an official interpretation, but to the admitting physician, dr. x it showed no significant infiltrate. well at hospital, she had a rapid influenza swab done, which was negative. she had a rapid rsv done, which is still not in the chart, but i believe i was told that it was negative. she also had a pertussis pcr swab done and a pertussis culture done, neither of which has result in the chart. i do know that the pertussis culture proved to be negative.,consultation: , public health department was notified of a case of suspected pertussis.,hospital course: , the baby was afebrile. required no oxygen in the hospital. actually fed reasonably well. did have one episode of coughing with slight emesis. appeared basically quite well between episodes. had no apnea witnessed and after overnight observation, the parents were anxious to go home. the patient was started on zithromax in the hospital.,condition and treatment: , the patient was in stable condition and good condition on exam at the time and was discharged home on zithromax to be followed up in the office within a week.,instructions to patient:, include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again.

preoperative diagnoses:,1. eyebrow ptosis.,2. dermatochalasia of upper and lower eyelids with tear trough deformity of the lower eyelid.,3. cervical facial aging with submental lipodystrophy.,operation:,1. hairline biplanar temporal browlift.,2. quadrilateral blepharoplasty with lateral canthopexy with arcus marginalis release and fat transposition over inferior orbital rim to lower eyelid.,3. cervical facial rhytidectomy with purse-string smas elevation with submental lipectomy.,assistant: ,none.,anesthesia: , general endotracheal anesthesia.,procedure: , the patient was placed in a supine position and prepped with general endotracheal anesthesia. local infiltration anesthesia with 1% xylocaine and 1:100,000 epinephrine was infiltrated in upper and lower eyelids.,markings were made and fusiform ellipse of skin was resected from the upper eyelid. the lower limb of the fusiform ellipse was at the superior palpebral fold. a 9 mm of upper eyelid skin was resected at the widest portion of the lips, which extended from medial canthal area to the lateral orbital rim. this was performed bilaterally and symmetrically and the skin was removed. incision was made through the pretarsal orbicularis with small amount of fat being removed from the medial and middle fat pocket. an incision was made over the superior orbital rim. subperiosteal dissection was performed over the forehead. the dissection proceeded medially. the corrugator and procerus muscles were carefully dissected from the supratrochlear nerves on both right and left side and cauterized.,hemostasis was achieved with electrocautery in this fashion. a 4-cm incision was made, and the forehead at the hairline, subcutaneous dissection was performed and extended over the frontalis muscle for approximately 4 cm. a subperiosteal dissection was performed after the fibers of the frontalis muscle were separated and subperiosteal dissection from the forehead lead the subperiosteal dissection from the upper eyelid. the incision was made in the lower lid just beneath the lashline. subcutaneous dissection was performed over the pretarsal and preseptal muscle. dissection was then proceeded down to the inferior orbital rim. the arcus marginalis was released and the lower eyelid fat was teased over the inferior orbital rim and sutured to the suborbicularis oculi fat and periosteum, which was separated from the inferior orbital rim. the orbital fat was sutured to the suborbicularis oculi fat with multiple preplaced sutures of 5-0 vicryl on a p2 needle. the upper eyelid incision was closed with a running subcuticular 6-0 prolene suture bilaterally. the forehead was then elevated, and the nonhairbearing forehead skin was resected 1.5 cm wide raising the tail of the eyebrow. the head of the eyebrow was felt to be elevated by the antagonistic frontalis muscle now that the accessory muscles specifically the corrugator and procerus and depressor supercilii were released and divided.,a lateral canthopexy was performed with 5-0 prolene suture on a c1 double-arm tapered needle being passed from the lateral commissure of the eyelid to the small stab incision being passed to the medial superior orbital rim and sutured to tighten the lower lid. the distal lateral resection of excessive lower eyelid skin was reduced at risk of eyelid malposition. the lower lid incision was closed after the redundancy of skin measuring approximately 3 mm was resected on both sides. closure was performed with interrupted 6-0 silk suture for the lower lid. the eyebrow hairline brow lift was closed with interrupted 4-0 pds suture, deep subcutaneous tissue, and dermis, and the skin closed with a running 5-0 prolene suture.,attention then was directed to the cervical facial rhytidectomy and purse-string smas elevation with submental lipectomy. incisions were made in preauricular area, postauricular area, mastoid and occipital area. subcutaneous dissection was performed to the nasolabial fold and cheek and extending across the neck in the midline. submental lipectomy was performed through the incision in the submental crease. fat was directly removed from the fascia.,hemostasis was achieved with electrocautery. a smas elevation was performed with a purse-string suture of 2-0 pds suture from temporalis fascia in front of the ear extending beneath the mandible and then brought back up to be sutured to the temporalis fascia. this was performed bilaterally and symmetrically. hemostasis was achieved with electrocautery. the cheek flap was brought back posteriorly and the cervical flap posteriorly and superiorly with redundant skin on the right massaged and closed. the skin of the cheek and neck were resected which was redundant after the ***** posteriorly and superiorly in the neck and transversely in the cheek.,closure was performed with interrupted 3-0 and 4-0 pds suture of deep subcutaneous tissue and dermis of the skin was closed with a running 5-0 prolene suture. drains were placed prior to final closure. a 7-mm flat jackson-pratt was then secured with 3-0 silk suture. dressing consisting of fluffs and kerlix and a 4-inch ace were applied to support mildly compressive dressing. scleral eye protectors were removed. maxitrol eye ointment was placed followed by swiss therapy eye pads. the patient tolerated the procedure well, and she returned to recovery room in satisfactory condition with foley catheter and pneumatic compression stockings, ted hose, two jackson-pratt drains, and an iv.

preoperative diagnosis:, carpal tunnel syndrome.,postoperative diagnosis:, carpal tunnel syndrome.,procedure: , endoscopic release of left transverse carpal ligament.,anesthesia:, monitored anesthesia care with regional anesthesia provided by surgeon. ,tourniquet time: , 12 minutes.,operative procedure in detail: , with the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner. the arm was exsanguinated. the tourniquet was elevated at 290 mmhg. construction lines were made on the left palm to identify the ring ray. a transverse incision was made in the palm between fcr and fcu, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin. blunt dissection exposed the antebrachial fascia. hemostasis was obtained with bipolar cautery. a distal based window in the antebrachial fascia was then fashioned. care was taken to protect the underlying contents. a synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,hamate sounds were then used to palpate the hood of hamate. the agee inside job was then inserted into the proximal incision. the transverse carpal ligament was easily visualized through the portal. using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end. the distal end of the transverse carpal ligament was then identified in the window. the blade was then elevated, and the agee inside job was withdrawn, dividing transverse carpal ligament under direct vision. after complete division of transverse carpal ligament, the agee inside job was reinserted. radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished. one cc of celestone was then introduced into the carpal tunnel and irrigated free. ,the wound was then closed with a running 3-0 prolene subcuticular stitch. steri-strips were applied and a sterile dressing was applied over the steri-strips. the tourniquet was deflated. the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.

preoperative diagnosis:, t11 compression fracture with intractable pain.,postoperative diagnosis:, t11 compression fracture with intractable pain.,operation performed:, unilateral transpedicular t11 vertebroplasty.,anesthesia:, local with iv sedation.,complications:, none.,summary: , the patient in the operating room in the prone position with the back prepped and draped in the sterile fashion. the patient was given sedation and monitored. using ap and lateral fluoroscopic projections the t11 compression fracture was identified. starting from the left side local anesthetic was used for skin wheal just lateral superior to the 10 o'clock position of the lateral aspect of the t11 pedicle on the left. the 13-gauge needle and trocar were then taken and placed to 10 o'clock position on the pedicle. at this point using ap and lateral fluoroscopic views, the needle and trocar were advanced into the vertebral body using the fluoroscopic images and making sure that the needle was lateral to the medial wall of the pedicle of the pedicle at all times. once the vertebral body was entered then using lateral fluoroscopic views, the needle was advanced to the junction of the anterior one third and posterior two thirds of the body. at this point polymethylmethacrylate was mixed for 60 seconds. once the consistency had hardened and the __________ was gone, incremental dose of the cement were injected into the vertebral body. it was immediately seen that the cement was going cephalad into the vertebral body and was exiting through the crack in the vertebra. a total 1.2 cc of cement was injected. on lateral view, the cement crushed to the right side as well. there was some dye infiltration into the disk space. there was no dye taken whatsoever into the posterior aspect of the epidural space or intrathecal canal.,at this point, as the needle was slowly withdrawn under lateral fluoroscopic images, visualization was maintained to ensure that none of the cement was withdrawn posteriorly into the epidural space. once the needle was withdrawn safely pressure was held over the site for three minutes. there were no complications. the patient was taken back to the recovery area in stable condition and kept flat for one hour. should be followed up the next morning.

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

preoperative diagnosis: , breast mass, left.,postoperative diagnosis:, breast mass, left.,procedure:, excision of left breast mass.,operation: , after obtaining an informed consent, the patient was taken to the operating room where he underwent general endotracheal anesthesia. the time-out process was followed. preoperative antibiotic was given. the patient was prepped and draped in the usual fashion. the mass was identified adjacent to the left nipple. it was freely mobile and it did not seem to hold the skin. an elliptical skin incision was made over the mass and carried down in a pyramidal fashion towards the pectoral fascia. the whole of specimen including the skin, the mass, and surrounding subcutaneous tissue and fascia were excised en bloc. hemostasis was achieved with the cautery. the specimen was sent to pathology and the tissues were closed in layers including a subcuticular suture of monocryl. a small pressure dressing was applied.,estimated blood loss was minimal and the patient who tolerated the procedure very well was sent to recovery room in satisfactory condition.

history of present illness:, the patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so. she states that she has not voided in the last 24 hours as well due to pain. she denies any leaking of fluid, vaginal bleeding, or uterine contractions. she reports good fetal movement. she denies any fevers, chills, or burning with urination.,review of systems: , positive for back pain in her lower back only. her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant. she continues to yell out for requesting pain medication and about how much "it hurts.",past medical history:,1. irritable bowel syndrome.,2. urinary tract infections times three. the patient is unsure if pyelo is present or not.,past surgical history:, denies.,allergies: , no known drug allergies.,medications: , phenergan and zofran twice a day. macrobid questionable.,gyn: , history of an abnormal pap, group b within normal limits. denies any sexually transmitted diseases.,ob history: , g1 is a term spontaneous vaginal delivery without complications, now a 6-year-old. g2 is current. gets her care at lyndhurst.,social history: , denies tobacco and alcohol use. she endorses marijuana use and a history of cocaine use five years ago. upon review of the baptist lab systems, the patient has had multiple positive urine drug screens and as recently as february 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,physical exam:,vital signs: blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees fahrenheit. fetal heart tones are 130s with moderate long-term variability. no paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,general: appears sedated, trashing intermittently, and then falling asleep in mid sentence.,cardiovascular: regular rate and rhythm.,pulmonary: clear to auscultation bilaterally.,back: tender to palpation in her lower back bilaterally, but no cva tenderness.,abdomen: tender to palpation in left lower quadrant. no guarding or rebound. normal bowel sounds.,extremities: scar track marks from bilateral arms.,pelvic: external vaginal exam is closed, long, high, and posterior. stool was felt in the rectum.,labs: , white count is 11.1, hemoglobin is 13.5, platelets are 279. cmp is within normal limits with an ast of 17, alt of 11, and creatinine of 0.6. urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,assessment and plan: ,the patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation. i spoke with dr. x who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to labor and delivery. plans are made for transfer at this time. this was discussed with dr. y who is in agreement with the plan.

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

the patient's abdomen was prepped and draped in the usual sterile fashion. a subumbilical skin incision was made. the veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. a subumbilical trocar was inserted. the camera was inserted in the panoramic view. the abdomen demonstrated some inflammation around the gallbladder. a 10-mm midepigastric trocar was inserted. a. 2 mm and 5 mm trocars were inserted. the most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,using the dissector, the cystic duct was identified and double hemoclips were invited well away from the cystic-common duct junction. the cystic artery was identified and double hemoclips applied. the gallbladder was taken down from the liver bed using endoshears and electrocautery. hemostasis was obtained. the gallbladder was removed from the midepigastric trocar site without difficulty. the trocars were removed and the skin incisions were reapproximated using 4-0 monocryl. steri-strips and sterile dressing were placed. the patient tolerated the procedure well and was taken to the recovery room in stable condition.

preoperative diagnoses:,1. chronic renal failure.,2. thrombosed left forearm arteriovenous gore-tex bridge fistula.,postoperative diagnosis:,1. chronic renal failure.,2. thrombosed left forearm arteriovenous gore-tex bridge fistula.,procedure performed:,1. fogarty thrombectomy, left forearm arteriovenous gore-tex bridge fistula.,2. revision of distal anastomosis with 7 mm interposition gore-tex graft.,anesthesia:, general with controlled ventillation.,gross findings: , the patient is a 58-year-old black male with chronic renal failure. he undergoes dialysis through the left forearm bridge fistula and has small pseudoaneurysms at the needle puncture sites level. there is narrowing at the distal anastomosis due to intimal hypoplasia and the vein beyond it was of good quality.,operative procedure: , the patient was taken to the or suite, placed in supine position. general anesthetic was administered. left arm was prepped and draped in appropriate manner. a pfannenstiel skin incision was created just below the antecubital crease just deeper to the subcutaneous tissue. utilizing both blunt and sharp dissections segment of the fistula was isolated ________ vessel loop. transverse graftotomy was created. a #4 fogarty catheter passed proximally and distally restoring inflow and meager inflow. a fistulogram was performed and the above findings were noted. in a retrograde fashion, the proximal anastomosis was patent. there was no narrowing within the forearm graft. both veins were flushed with heparinized saline and controlled with a vascular clamp. a longitudinal incision was then created in the upper arm just deep into the subcutaneous tissue fascia. utilizing both blunt and sharp dissection, the brachial vein as well as distal anastomosis was isolated. the distal anastomosis amputated off the fistula and oversewn with continuous running #6-0 prolene suture tied upon itself. the vein was controlled with vascular clamps. longitudinal venotomy created along the anteromedial wall. a 7 mm graft was brought on to the field and this was cut to shape and size. this was sewed to the graft in an end-to-side fashion with u-clips anchoring the graft at the heel and toe with interrupted #6-0 prolene sutures. good backflow bleeding was confirmed. the vein flushed with heparinized saline and graft was controlled with vascular clamp. the end of the insertion graft was cut to shape in length and sutured to the graft in an end-to-end fashion with continuous running #6-0 prolene suture. good backflow bleeding was confirmed. the graftotomy was then closed with interrupted #6-0 prolene suture. flow through the fistula was permitted, a good flow passed. the wound was copiously irrigated with antibiotic solution. sponge, needles, instrument counts were correct. all surgical sites were inspected. good hemostasis was noted. the incision was closed in layers with absorbable sutures. sterile dressing was applied. the patient tolerated the procedure well and returned to the recovery room in apparent stable condition.

subjective:, the patient is brought in by an assistant with some of his food diary sheets. they wonder if the patient needs to lose anymore weight.,objective:, the patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month. he has lost a total of 34-1/2 pounds. i praised this. i went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free kool-aid, sugar-free pudding, and diet pop. i encouraged him to continue all of that, as well as his regular physical activity.,assessment:, the patient is losing weight at an acceptable rate. he needs to continue keeping a food diary and his regular physical activity.,plan:, the patient plans to see dr. xyz at the end of may 2005. i recommended that they ask dr. xyz what weight he would like for the patient to be at. follow up will be with me june 13, 2005.

preoperative diagnosis: , right chronic subdural hematoma.,postoperative diagnosis: ,right chronic subdural hematoma.,type of operation: , right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,anesthesia: , general endotracheal anesthesia.,estimated blood loss: , 100 cc.,operative procedure:, in preoperative identification, the patient was taken to the operating room and placed in supine position. following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery. table was turned. the right shoulder roll was placed. the head was turned to the left and rested on a doughnut. the scalp was shaved, and then prepped and draped in usual sterile fashion. incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss. the parietal boss incision was opened. it was about an inch and a half in length. it was carried down to the skull. self-retaining retractor was placed. a bur hole was now fashioned with the perforator. this was widened with a 2-mm kerrison punch. the dura was now coagulated with bipolar electrocautery. it was opened in a cruciate-type fashion. the dural edges were coagulated back to the bony edges. there was egress of a large amount of liquid. under pressure, we irrigated for quite sometime until irrigation was returning mostly clear. a subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision. it was secured with a 3-0 nylon suture. the area was closed with interrupted inverted 2-0 vicryl sutures. the skin was closed with staples. sterile dressing was applied. the patient was subsequently returned back to anesthesia. he was extubated in the operating room, and transported to pacu in satisfactory condition.

history of present illness: , this is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung. the patient also has a positive history of smoking in the past. at the present time, he is admitted for continued,management of respiratory depression with other medical complications. the patient was treated for multiple problems at jefferson hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter. in addition, he also developed cardiac complications including atrial fibrillation. the patient was evaluated by the cardiologist as well as the pulmonary service and urology. he had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008. he subsequently underwent cardiac arrest and he was resuscitated at that time. he was intubated and placed on mechanical ventilatory support. subsequent weaning was unsuccessful. he then had a tracheostomy placed.,current medications:,1. albuterol.,2. pacerone.,3. theophylline,4. lovenox.,5. atrovent.,6. insulin.,7. lantus.,8. zestril.,9. magnesium oxide.,10. lopressor.,11. zegerid.,12. tylenol as needed.,allergies:, penicillin.,past medical history:,1. history of coal miner's disease.,2. history of copd.,3. history of atrial fibrillation.,4. history of coronary artery disease.,5. history of coronary artery stent placement.,6. history of gastric obstruction.,7. history of prostate cancer.,8. history of chronic diarrhea.,9. history of pernicious anemia.,10. history of radiation proctitis.,11. history of anxiety.,12. history of ureteral stone.,13. history of hydronephrosis.,social history: , the patient had been previously a smoker. no other could be obtained because of tracheostomy presently.,family history: , noncontributory to the present condition and review of his previous charts.,systems review: , the patient currently is agitated. rapidly moving his upper extremities. no other history regarding his systems could be elicited from the patient.,physical exam:,general: the patient is currently agitated with some level of distress. he has rapid respiratory rate. he is responsive to verbal commands by looking at the eyes.,vital signs: as per the monitors are stable.,extremities: inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage ii especially over the dorsum of the hands and forearm areas. there is also edema of the forearm extending up to the mid upper arm area. palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect. there is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,impression:,1. ulceration of bilateral upper extremities.,2. cellulitis of upper extremities.,3. lymphedema of upper extremities.,4. other noninfectious disorders of lymphatic channels.,5. ventilatory-dependent respiratory failure.

exam: , ct scan of the abdomen and pelvis without and with intravenous contrast.,clinical indication: , left lower quadrant abdominal pain.,comparison: , none.,findings: , ct scan of the abdomen and pelvis was performed without and with intravenous contrast. total of 100 ml of isovue was administered intravenously. oral contrast was also administered.,the lung bases are clear. the liver is enlarged and decreased in attenuation. there are no focal liver masses.,there is no intra or extrahepatic ductal dilatation.,the gallbladder is slightly distended.,the adrenal glands, pancreas, spleen, and left kidney are normal.,a 12-mm simple cyst is present in the inferior pole of the right kidney. there is no hydronephrosis or hydroureter.,the appendix is normal.,there are multiple diverticula in the rectosigmoid. there is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. these findings are consistent with diverticulitis. no pneumoperitoneum is identified. there is no ascites or focal fluid collection.,the aorta is normal in contour and caliber.,there is no adenopathy.,degenerative changes are present in the lumbar spine.,impression: , findings consistent with diverticulitis. please see report above.

chief complaint:, chronic otitis media.,history of present illness:, this is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth. there is also associated chronic nasal congestion. there had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection. he is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,allergies:, none.,medications:, none.,family history:, noncontributory.,medical history: , mild reflux.,previous surgeries:, none.,social history: , the patient is not in daycare. there are no pets in the home. there is no secondhand tobacco exposure.,physical examination: , examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present. left ear is still little bit black. nose, moderate inferior turbinate hypertrophy. no polyps or purulence. oral cavity, oropharynx 2+ tonsils. no exudates. neck, no nodes, masses or thyromegaly. lungs are clear to a&p. cardiac exam, regular rate and rhythm. no murmurs. abdomen is soft and nontender. positive bowel sounds.,impression: , chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,plan:, the patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.

history of present illness: , i have seen abc today. he is a very pleasant gentleman who is 42 years old, 344 pounds. he is 5'9". he has a bmi of 51. he has been overweight for ten years since the age of 33, at his highest he was 358 pounds, at his lowest 260. he is pursuing surgical attempts of weight loss to feel good, get healthy, and begin to exercise again. he wants to be able to exercise and play volleyball. physically, he is sluggish. he gets tired quickly. he does not go out often. when he loses weight he always regains it and he gains back more than he lost. his biggest weight loss is 25 pounds and it was three months before he gained it back. he did six months of not drinking alcohol and not taking in many calories. he has been on multiple commercial weight loss programs including slim fast for one month one year ago and atkin's diet for one month two years ago.,past medical history: , he has difficulty climbing stairs, difficulty with airline seats, tying shoes, used to public seating, difficulty walking, high cholesterol, and high blood pressure. he has asthma and difficulty walking two blocks or going eight to ten steps. he has sleep apnea and snoring. he is a diabetic, on medication. he has joint pain, knee pain, back pain, foot and ankle pain, leg and foot swelling. he has hemorrhoids.,past surgical history: , includes orthopedic or knee surgery.,social history: , he is currently single. he drinks alcohol ten to twelve drinks a week, but does not drink five days a week and then will binge drink. he smokes one and a half pack a day for 15 years, but he has recently stopped smoking for the past two weeks.,family history: , obesity, heart disease, and diabetes. family history is negative for hypertension and stroke.,current medications:, include diovan, crestor, and tricor.,miscellaneous/eating history: ,he says a couple of friends of his have had heart attacks and have had died. he used to drink everyday, but stopped two years ago. he now only drinks on weekends. he is on his second week of chantix, which is a medication to come off smoking completely. eating, he eats bad food. he is single. he eats things like bacon, eggs, and cheese, cheeseburgers, fast food, eats four times a day, seven in the morning, at noon, 9 p.m., and 2 a.m. he currently weighs 344 pounds and 5'9". his ideal body weight is 160 pounds. he is 184 pounds overweight. if he lost 70% of his excess body weight that would be 129 pounds and that would get him down to 215.,review of systems: , negative for head, neck, heart, lungs, gi, gu, orthopedic, or skin. he also is positive for gout. he denies chest pain, heart attack, coronary artery disease, congestive heart failure, arrhythmia, atrial fibrillation, pacemaker, pulmonary embolism, or cva. he denies venous insufficiency or thrombophlebitis. denies shortness of breath, copd, or emphysema. denies thyroid problems, hip pain, osteoarthritis, rheumatoid arthritis, gerd, hiatal hernia, peptic ulcer disease, gallstones, infected gallbladder, pancreatitis, fatty liver, hepatitis, rectal bleeding, polyps, incontinence of stool, urinary stress incontinence, or cancer. he denies cellulitis, pseudotumor cerebri, meningitis, or encephalitis.,physical examination: ,he is alert and oriented x 3. cranial nerves ii-xii are intact. neck is soft and supple. lungs: he has positive wheezing bilaterally. heart is regular rhythm and rate. his abdomen is soft. extremities: he has 1+ pitting edema.,impression/plan:, i have explained to him the risks and potential complications of laparoscopic gastric bypass in detail and these include bleeding, infection, deep venous thrombosis, pulmonary embolism, leakage from the gastrojejuno-anastomosis, jejunojejuno-anastomosis, and possible bowel obstruction among other potential complications. he understands. he wants to proceed with workup and evaluation for laparoscopic roux-en-y gastric bypass. he will need to get a letter of approval from dr. xyz. he will need to see a nutritionist and mental health worker. he will need an upper endoscopy by either dr. xyz. he will need to go to dr. xyz as he previously had a sleep study. we will need another sleep study. he will need h. pylori testing, thyroid function tests, lfts, glycosylated hemoglobin, and fasting blood sugar. after this is performed, we will submit him for insurance approval.

preoperative diagnosis:, obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,postoperative diagnosis:, obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,operation:, tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,anesthesia:, general anesthetics.,history: , this is a 51-year-old gentleman here with his wife. she confirms the history of loud snoring at night with witnessed apnea. the result of the sleep study was reviewed. this showed moderate sleep apnea with significant desaturation. the patient was unable to tolerate treatment with cpap. at the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate. a tortuous appearance of the septum also was observed. this morning, i talked to the patient and his wife about the findings. i reviewed the ct images. he has no history of sinus infections and does not recall a history of nasal trauma. we discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway. depending on the findings of surgery, i explained that i might remove that bone spur that we are seeing within the nasal passage. i will get the best look at it when he is asleep. we discussed recovery as well. he visited with dr. xyz about the anesthetic produce.,procedure:,: general tracheal anesthetic was administered by dr. xyz and mr. radke. afrin drops were placed in both nostrils and a cottonoid soaked with afrin was placed in each side of the nose. a crowe-davis mouth gag was placed. the tonsils were very large and touched the uvula. the uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars. also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate. retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present. a very crowded pharynx was appreciated. the tonsils were first removed using electrodissection technique. hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut. the tonsil fossae were injected with 0.25% marcaine with 1:200,000 epinephrine. there already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula. the uvula was grasped with the alice clamp. i palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate. we switched over from the bayonet cautery to the blunt needle tip electrocautery. the planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar. this incision was then deepened with the electrocautery on a cutting current. the uvular artery just to the right of the midline was controlled with the suction electrocautery. the posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty. a portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology. the tonsil fossae were injected with 0.25% marcaine with 1:200,000 epinephrine. the soft palate was also injected with 0.25% marcaine with 1:200,000 epinephrine. the posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures. the posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures. a much improved appearance of the oropharynx with a greatly improved airway was appreciated. a moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed. i removed the cottonoids from both nostrils. speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left. the septum was injected with 0.25% marcaine with 1:200,000 epinephrine using a separate syringe and needle. a #15 blade was used to make a left cheilion incision.,mucoperichondrium and mucoperiosteum were elevated with the cottle elevator. when we reached the deflected portion of the vomer, this was separated from the septal cartilage with a freer elevator. the right-sided mucoperiosteum was elevated with the freer elevator and then with takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected. this tissue also was sent as a separate specimen to pathology. the intraseptal space was irrigated with saline and suctioned. the nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut. i observed no evidence of purulent secretion or polyp formation within the nostrils. the inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides. there was good support for the nasal tip and the dorsum and there was good hemostasis within the nose. no packing was used in the nostrils. polysporin ointment was introduced into both nostrils. the mouth gag was reintroduced and the pack removed from the nasopharynx. the nose and throat were irrigated with saline and suctioned. an orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed. sponge and needle count were reported correct. the mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition. he tolerated the operation excellently. estimated blood loss was about 15-20 cc. in the recovery room, i observed that he was moving air well and i spoke with his wife about the findings of surgery.

admitting diagnoses,1. acute gastroenteritis.,2. nausea.,3. vomiting.,4. diarrhea.,5. gastrointestinal bleed.,6. dehydration.,discharge diagnoses,1. acute gastroenteritis, resolved.,2. gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,brief h&p and hospital course: , this patient is a 56-year-old male, a patient of dr. x with 25-pack-year history, also a history of diabetes type 2, dyslipidemia, hypertension, hemorrhoids, chronic obstructive pulmonary disease, and a left lower lobe calcified granuloma that apparently is stable at this time. this patient presented with periumbilical abdominal pain with nausea, vomiting, and diarrhea for the past 3 days and four to five watery bowel movements a day with symptoms progressively getting worse. the patient was admitted into the er and had trop x1 done, which was negative and ecg showed to be of normal sinus rhythm.,lab findings initially presented with a hemoglobin of 13.1, hematocrit of 38.6 with no elevation of white count. upon discharge, his hemoglobin and hematocrit stayed at 10.9 and 31.3 and he was still having stool guaiac positive blood, and a stool study was done which showed few white blood cells, negative for clostridium difficile and moderate amount of occult blood and moderate amount of rbcs. the patient's nausea, vomiting, and diarrhea did resolve during his hospital course. was placed on iv fluids initially and on hospital day #2 fluids were discontinued and was started on clear liquid diet and diet was advanced slowly, and the patient was able to tolerate p.o. well. the patient also denied any abdominal pain upon day of discharge. the patient was also started on prednisone as per gi recommendations. he was started on 60 mg p.o. amylase and lipase were also done which were normal and ldh and crp was also done which are also normal and lfts were done which were also normal as well.,plan: , the plan is to discharge the patient home. he can resume his home medications of prandin, actos, lipitor, glucophage, benicar, and advair. we will also start him on a tapered dose of prednisone for 4 weeks. we will start him on 15 mg p.o. for seven days. then, week #2, we will start him on 40 mg for 1 week. then, week #3, we will start him on 30 mg for 1 week, and then, 20 mg for 1 week, and then finally we will stop. he was instructed to take tapered dose of prednisone for 4 weeks as per the gi recommendations.

history of present illness: , this is a 3-year-old female patient, who was admitted today with a history of gagging. she was doing well until about 2 days ago, when she developed gagging. no vomiting. no fever. she has history of constipation. she normally passes stool every two days after giving an enema. no rectal bleeding. she was brought to the hospital with some loose stool. she was found to be dehydrated. she was given iv fluid bolus, but then she started bleeding from g-tube site. there was some fresh blood coming out of the g-tube site. she was transferred to picu. she is hypertensive. intensivist dr. x requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,past medical history: , peho syndrome, infantile spasm, right above knee amputation, developmental delay, g-tube fundoplication.,past surgical history: , g-tube fundoplication on 05/25/2007. right above knee amputation.,allergies:, none.,diet: , she is npo now, but at home she is on pediasure 4 ounces 3 times a day through g-tube, 12 ounces of water per day.,medications: , albuterol, pulmicort, miralax 17 g once a week, carnitine, phenobarbital, depakene and reglan.,family history:, positive for cancer.,past laboratory evaluation: , on 12/27/2007; wbc 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000. kub showed large stool with dilated small and large bowel loops. sodium 140, potassium 4.4, chloride 89, co2 21, bun 61, creatinine 2, ast 92 increased, alt 62 increased, albumin 5.3, total bilirubin 0.1. earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000. pt 58 increased, inr 6.6 increased, ptt 75.9 increased.,physical examination: ,vital signs: temperature 99 degrees fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,general: she is intubated.,heent: atraumatic. she is intubated.,lungs: good air entry bilaterally. no rales or wheezing.,abdomen: distended. decreased bowel sounds.,genitalia: grossly normal female.,cns: she is sedated.,impression: , a 3-year-old female patient with history of passage of blood through g-tube site with coagulopathy. she has a history of g-tube fundoplication, developmental delay, peho syndrome, which is progressive encephalopathy optic atrophy.,plan: ,plan is to give vitamin k, ffp, blood transfusion. consider upper endoscopy. procedure and informed consent discussed with the family.

preoperative diagnosis: , chronic otitis media.,postoperative diagnosis: , chronic otitis media.,procedure performed: , bilateral myringotomy tubes and adenoidectomy.,indications for procedure:, the patient is an 8-year-old child with history of recurrent otitis media. the patient has had previous tube placement. tubes have since plugged and are no more functioning. the patient has had recent recurrent otitis media. risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother. mother wished to proceed with the surgery.,procedure in detail: , the patient was brought to the room, placed supine. the patient was given general endotracheal anesthesia. starting on the left ear, under microscopic visualization, the ear was cleaned of wax. a bobbin tube was found stuck to the tympanic membrane. this was removed. after removing the tube the patient was found to have microperforation through which serous fluid was draining. a fresh myringotomy was made in the anterior inferior quadrant. more serous fluid was aspirated from middle ear space. the new bobbin tube was easily placed. floxin drops were placed in the ear. in the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane. there was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane. a fresh myringotomy incision was made in the anterior inferior quadrant. more serous fluid was drained out of middle ear space. the tube was easily placed and floxin drops were placed in the ear. this completes tube portion of the surgery. the patient was then turned and placed in the rose position. shoulder roll was placed for neck extension. using a small mcivor mouth gag mouth was held open. using a rubber catheter the soft palate was retracted. under mirror visualization, the nasopharynx was examined. the patient was found to have minimal adenoidal tissue. this was removed using a suction bovie. the patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition. there were no intraoperative complications. needle and sponge count correct. estimated blood loss none.

procedure: , colonoscopy.,indications: , hematochezia, personal history of colonic polyps.,medications:, midazolam 2 mg iv, fentanyl 100 mcg iv,procedure:, a history and physical has been performed, and patient medication allergies have been reviewed. the patient's tolerance of previous anesthesia has been reviewed. the risks and benefits of the procedure and the sedation options and risks were discussed with the patient. all questions were answered and informed consent was obtained. mental status examination: alert and oriented. airway examination: normal oropharyngeal airway and neck mobility. respiratory examination: clear to auscultation. cv examination: rrr, no murmurs, no s3 or s4. asa grade assessment: p1 a normal healthy patient. after reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure. the anesthesia plan was to use conscious sedation. immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives. the heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure. the physical status of the patient was re-assessed after the procedure. after i obtained informed consent, the scope was passed under direct vision. throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously. the colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & ic valve. the quality of the prep was good. the patient tolerated the procedure well.,findings:,1. a sessile, non-bleeding polyp was found in the rectum. the polyp was 5 mm in size. polypectomy was performed with a saline injection-lift technique using the snare. resection and retrieval were complete. estimated blood loss was minimal.,2. one pedunculated, non-bleeding polyp was found in the sigmoid colon. the polyp was 7 mm in size. polypectomy was performed with a hot forceps. resection and retrieval were complete. estimated blood loss was minimal.,3. multiple large-mouthed diverticula were found in the descending colon.,4. internal, non-bleeding, prolapsed with spontaneous reduction (grade ii) hemorrhoids were found on retroflexion.,impression:,1. one 5 mm benign appearing polyp in the rectum. resected and retrieved.,2. one 7 mm polyp in the sigmoid colon. resected and retrieved.,3. diverticulosis.,4. internal hemorrhoids were found.,recommendation:,1. high fiber diet.,2. await pathology results.,3. repeat colonoscopy for surveillance in 3 years.,4. the findings and recommendations were discussed with the patient.,cpt code(s):,45385, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,icd9 code(s):,211.4, benign neoplasm of rectum and anal canal.,211.3, benign neoplasm of colon.,562.10, diverticulosis of colon (without mention of hemorrhage).,455.2, internal hemorrhoids with other complication,578.1, blood in stool.,v12.72, personal history of colonic polyps.

procedure performed:,1. selective ascending aortic arch angiogram.,2. selective left common carotid artery angiogram.,3. selective right common carotid artery angiogram.,4. selective left subclavian artery angiogram.,5. right iliac angio with runoff.,6. bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,indications for procedure: , tia, aortic stenosis, postoperative procedure. moderate carotid artery stenosis.,estimated blood loss:, 400 ml.,specimens removed:, not applicable.,technique of procedure: , after obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. the right groin was prepped and draped in the usual sterile fashion. lidocaine 2% was used for infiltration anesthesia. using modified seldinger technique, a 6-french sheath was placed into the right common femoral artery and vein without complication. using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a v-tech catheter over an 0.035-inch wire.,angiographic findings:,1. type 2 aortic arch.,2. left subclavian artery was patent.,3 left vertebral artery was patent.,4. left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. closure was with a 6-french angio-seal of the artery, and the venous sheath was sutured in.,plan:, continue aspirin, plavix, and coumadin to an inr of 2 with a carotid duplex followup.

cc:, headache.,hx: ,the patient is an 8y/o rhm with a 2 year history of early morning headaches (3:00-6:00am) intermittently relieved by vomiting only. he had been evaluated 2 years ago and an eeg was "normal" then, but no brain imaging was performed. his headaches progressively worsened, especially in the past two months prior to this presentation. for 2 weeks prior to his 1/25/93 evaluation at uihc, he would awake screaming. his parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,vermox was prescribed and arrangements were made for a neurologic evaluation. on the evening of 1/24/93 the patient awoke screaming and began to vomit. this was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. he was taken to a local er and a brain ct revealed an intracranial mass. he was given decadron and phenytoin and transferred to uihc for further evaluation.,meds:, noted above.,pmh: ,1)born at 37.5 weeks gestation by uncomplicated vaginal delivery to a g1p0 mother. pregnancy complicated by vaginal bleeding at 7 months. met developmental milestones without difficulty. 2) frequent otitis media, now resolved. 3) immunizations were "up to date.",fhx:, non-contributory.,shx:, lives with biologic father and mother. no siblings. in 3rd grade (mainstream) and maintaining good marks in schools.,exam:, bp121/57mmhg hr103 rr16 36.9c,ms: sleepy, but cooperative.,cn: eom full and smooth. advanced papilledema, ou. vfftc. pupils 4/4 decreasing to 2/2. right lower facial weakness. tongue midline upon protrusion. corneal reflexes intact bilaterally.,motor: 5/5 strength. slightly increased muscle on right side.,sensory. no deficit to pp/vib noted.,coord: normal fnf, hks and ram, bilaterally.,station: mild truncal ataxia. tends to fall backward.,reflexes: bue 2+/2+, patellar 3/3, ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,gen exam: unremarkable.,course:, the patient was continued on dilantin 200mg qd and decadron 5mg iv q6hrs. brain mri, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on t2 weighted images. there were areas of cystic formation at its periphery. the mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. there was no sign of uncal herniation. he underwent bilateral vp shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. he then received 5040cgy of radiation therapy in 28 fractions completed on 3/25/93. a 3/20/95 neuropsychological evaluation revealed low average intellect on the wisc-iii. there were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. he remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. mri revealed tumor progression and he was subsequently placed on carboplatin/vp-16 (cg 9933 protocol chemotherapy, regimen a). he was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.

reason for consult: , genetic counseling.,history of present illness: , the patient is a very pleasant 61-year-old female with a strong family history of colon polyps. the patient reports her first polyps noted at the age of 50. she has had colonoscopies required every five years and every time she has polyps were found. she reports that of her 11 brothers and sister 7 have had precancerous polyps. she does have an identical twice who is the one of the 11 who has never had a history of polyps. she also has history of several malignancies in the family. her father died of a brain tumor at the age of 81. there is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement. her sister died at the age of 65 breast cancer. she has two maternal aunts with history of lung cancer both of whom were smoker. also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer. there is no other cancer history.,past medical history:, significant for asthma.,current medications: , include serevent two puffs daily and nasonex two sprays daily.,allergies: , include penicillin. she is also allergic seafood; crab and mobster.,social history: , the patient is married. she was born and raised in south dakota. she moved to colorado 37 years ago. she attended collage at the colorado university. she is certified public account. she does not smoke. she drinks socially.,review of systems: ,the patient denies any dark stool or blood in her stool. she has had occasional night sweats and shortness of breath, and cough associated with her asthma. she also complains of some acid reflux as well as anxiety. she does report having knee surgery for torn acl on the left knee and has some arthritis in that knee. the rest of her review of systems is negative.,physical exam:,vitals:

history of present illness: this is a 91-year-old female who was brought in by family. apparently, she was complaining that she felt she might have been poisoned at her care facility. the daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now. the patient apparently had a little bit of dry heaves, but no actual vomiting. she had just finished eating dinner. no one else in the facility has been ill.,past medical history: remarkable for previous abdominal surgeries. she has a pacemaker. she has a history of recent collarbone fracture.,review of systems: very difficult to get from the patient herself. she seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her. she initially stated that everything was wrong, but could not specify any specific complaints. denies chest pain, back pain, or abdominal pain. denies any extremity symptoms or complaints.,social history: the patient is a nonsmoker. she is accompanied here with daughter who brought her over here. they were visiting the patient when this episode occurred.,medications: please see list.,allergies: none.,physical examination: vital signs: the patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air. general: the patient is an elderly frail looking little lady lying on the gurney. she is awake, alert, and not really wanted to answer most of the questions i asked her. she does have a tremor with her mouth, which the daughter states has been there for "many years". heent: eye exam is unremarkable. oral mucosa is still moist and well hydrated. posterior pharynx is clear. neck: supple. lungs: actually clear with good breath sounds. there are no wheezes, no rales, or rhonchi. good air movement. cardiac: without murmur. abdomen: soft. i do not elicit any tenderness. there is no abdominal distention. bowel sounds are present in all quadrants. skin: skin is without rash or petechiae. there is no cyanosis. extremities: no evidence of any trauma to the extremities.,emergency department course: i had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of ativan intramuscularly. after about half an hour, i came back to talk to the patient and the family, the patient states that she feels better. family states she seems more calm. they do not want to pursue any further workup at this time.,impression: acute episode of agitation.,plan: at this time, i had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode. the patient herself has good vital signs. she does not seem to have any specific acute process going on and seemed to feel comfortable after the ativan was given, a small quantity was given to the patient. family and daughter specifically did not want to pursue any workup at this point, which at this point i think is reasonable and we will have her follow up with abc. she is discharged in stable condition.

preoperative diagnoses:,1. feeding disorder.,2. down syndrome.,3. congenital heart disease.,postoperative diagnoses:,1. feeding disorder.,2. down syndrome.,3. congenital heart disease.,operation performed: , gastrostomy.,anesthesia: , general.,indications: ,this 6-week-old female infant had been transferred to children's hospital because of down syndrome and congenital heart disease. she has not been able to feed well and in fact has to now be ng tube fed. her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,operative procedure: ,after the induction of general anesthetic, the abdomen was prepped and draped in usual manner. transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection. the muscle was divided and the peritoneal cavity entered. the greater curvature of the stomach was grasped with a babcock clamp and brought into the operative field. the site for gastrostomy was selected and a pursestring suture of #4-0 nurolon placed in the gastric wall. a 14-french 0.8 cm mic-key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube. following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 nurolon affixing the stomach to the posterior fascia. the anterior fascia was then closed with #3-0 vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular monocryl. the balloon was inflated to the full 5 ml. a sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,

chief complaint: , aplastic anemia.,history of present illness: , this is a very pleasant 72-year-old woman, who i have been following for her pancytopenia. after several bone marrow biopsies, she was diagnosed with aplastic anemia. she started cyclosporine and prednisone on 03/30/10. she was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. her cyclosporine level was 555. it was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.,overall, she tells me that now she feels quite well since leaving the hospital. she was transfused 2 units of packed red blood cells while in the hospital. repeat cbc from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.,current medications:, folic acid, aciphex, miralax, trazodone, prednisone for 5 days every 4 weeks, bactrim double strength 1 tablet b.i.d. on mondays, wednesdays and fridays.,allergies: ,no known drug allergies.,review of systems: , as per the hpi, otherwise negative.,past medical history:,1. hypertension.,2. gerd.,3. osteoarthritis.,4. status post tonsillectomy.,5. status post hysterectomy.,6. status post bilateral cataract surgery.,7. esophageal stricture status post dilatation approximately four times.,social history: ,she has no tobacco use. she has rare alcohol use. she has three children and is a widow. her husband died after they were married only eight years. she is retired.,family history: , her sister had breast cancer.,physical exam:,vit:

preoperative diagnosis:, left nasolabial fold scar deformity with effacement of alar crease.,postoperative diagnosis:, left nasolabial fold scar deformity with effacement of alar crease.,procedures performed:,1. left midface elevation with nasolabial fold elevation.,2. left nasolabial fold z-plasty and right symmetrization midface elevation.,anesthesia: , general endotracheal intubation.,estimated blood loss: , less than 25 ml.,fluids: , crystalloid,cultures taken: , none.,patient's condition: , stable.,implants: , coapt endotine midface b 4.5 bioabsorbable implants, reference #cfd0200197, lot #01447 used on the right and used on the left side.,identification: , this patient is well known to the stanford plastic surgery service. the patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity. in particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry. the patient was seen in consultation and felt to be a surgical candidate for improvement. risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication. the patient understood these risks and benefits and consented to the operation.,procedure in detail: , the patient was taken to or and placed supine on the operating table. dose of antibiotics was given to the patient. compression devices were placed on the lower extremities to prevent the knee embolic events. the patient was turned to 180 degrees. the ett tube was secured and the area was then prepped and draped in usual sterile fashion. a head wrap was then placed on the position and we then began our local. of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access. local consisting a 50:50 mix of 0.25% marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves. this was done bilaterally. we then marked the nasolabial fold and began with the elevation of the left midface.,we began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue. we continued down to the lateral orbital rim until we identified periosteum. we then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially. care was taken to preserve the infraorbital nerve and that was visualized after elevation. we then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,we then used our endotine coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the coapt bioabsorbable screw. after this was then carried out, we then clipped and cut as well as the end of the screw. satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 monocryl. several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry. excess skin along the incision was then removed as well the skin from just lateral to the canthus. care was taken to leave the orbicularis muscle down. we then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 prolenes lateral to the canthus.,we then turned our attention to performing the z-plasty portion of the case. a z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour. this was carried out using a 15 blade down to subcutaneous tissue. the flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture. at this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally. as such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision. we carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,at this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our endotine midface implant into the desired area and then elevated slightly just for symmetry only. this was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 pds and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 prolene lateral to the canthus.,at this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease. satisfied with our procedures, we then placed cool compresses on to the eyes.,the patient was then extubated and brought to the pacu in stable condition.,dr. x was present and scrubbed for the entire case and actively participated during all key elements. dr. y was available and participated in the portions of the case as well.

reason for consultation: , syncope.,history of present illness: ,the patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the emergency room following an episode of syncope. the patient relates that he may have had a seizure activity prior to that. prior to the episode, he denies having any symptoms of chest pain or shortness of breath. no palpitation. presently, he is comfortable, lying in the bed. as per the patient, no prior cardiac history.,coronary risk factors: , history of hypertension. no history of diabetes mellitus. nonsmoker. cholesterol status is borderline elevated. no history of established coronary artery disease. family history noncontributory.,past medical history: ,hypertension, hyperlipidemia, recently diagnosed with parkinson's, as a parkinson's tremor, admitted for syncopal evaluation.,past surgical history: ,back surgery, shoulder surgery, and appendicectomy.,family history: , nonsignificant.,medications:,1. pain medications.,2. thyroid supplementation.,3. lovastatin 20 mg daily.,4. propranolol 20 b.i.d.,5. protonix.,6. flomax.,allergies:, none.,personal history:, he is married. nonsmoker. does not consume alcohol. no history of recreational drug use.,review of systems,constitutional: no weakness, fatigue, or tiredness.,heent: no history of cataract or glaucoma.,cardiovascular: no congestive heart failure. no arrhythmias.,respiratory: no history of pneumonia or valley fever.,gastrointestinal: no nausea, vomiting, hematemesis, or melena.,urological: no frequency or urgency.,musculoskeletal: arthritis and muscle weakness.,skin: nonsignificant.,neurologic: no tia or cva. no seizure disorder.,endocrine/hematologic: nonsignificant.,physical examination,vital signs: pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,heent: atraumatic and normocephalic.,neck: neck veins are flat. no significant carotid bruits.,lungs: air entry is bilaterally decreased.,heart: pmi is displaced. s1 and s2 are regular.,abdomen: soft and nontender. bowel sounds are present.,extremities: no edema. pulses are palpable. no clubbing or cyanosis. the patient is moving all extremities; however, the patient has tremors.,radiological data: , ekg reveals normal sinus rhythm with underlying nonspecific st-t changes secondary to tremors.,laboratory data: , h&h stable. white count of 14. bun and creatinine are within normal limits. cardiac enzyme profile is negative. ammonia level is elevated at 69. ct angiogram of the chest, no evidence of pulmonary embolism. chest x-ray is negative for acute changes. ct of the head, unremarkable, chronic skin changes. liver enzymes are within normal limits.,impression:,1. the patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.

procedure: , newborn circumcision.,indications: , parental preference.,anesthesia:, dorsal penile nerve block.,description of procedure:, the baby was prepared and draped in a sterile manner. lidocaine 1% 4 ml without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock. the penile foreskin was removed using a xxx gomco. hemostasis was achieved with minimal blood loss. there was no sign of infection. the baby tolerated the procedure well. vaseline was applied to the penis, and the baby was diapered by nursing staff.

past medical history: , significant for arthritis in her knee, anxiety, depression, high insulin levels, gallstone attacks, and pcos.,past surgical history: , none.,social history: , currently employed. she is married. she is in sales. she does not smoke. she drinks wine a few drinks a month.,current medications: , she is on carafate and prilosec. she was on metformin, but she stopped it because of her abdominal pains.,allergies: , she is allergic to penicillin.,review of systems:, negative for heart, lungs, gi, gu, cardiac, or neurologic. denies specifically asthma, allergies, high blood pressure, high cholesterol, diabetes, chronic lung disease, ulcers, headache, seizures, epilepsy, strokes, thyroid disorder, tuberculosis, bleeding, clotting disorder, gallbladder disease, positive liver disease, kidney disease, cancer, heart disease, and heart attack.,physical examination: , she is afebrile. vital signs are stable. heent: eomi. perrla. neck is soft and supple. lungs clear to auscultation. she is mildly tender in the abdomen in the right upper quadrant. no rebound. abdomen is otherwise soft. positive bowel sounds. extremities are nonedematous. ultrasound reveals gallstones, no inflammation, common bile duct in 4 mm.,impression/plan: , i have explained the risks and potential complications of laparoscopic cholecystectomy in detail including bleeding, infection, deep venous thrombosis, pulmonary embolism, cystic leak, duct leak, possible need for ercp, and possible need for further surgery among other potential complications. she understands and we will proceed with the surgery in the near future.,

chief complaint: , mental status changes after a fall.,history: , ms. abc is a 76-year-old female with alzheimer's, apparently is normally very talkative, active, independent, but with advanced alzheimer's. apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. she was very confused, incomprehensible speech, and was not responding appropriately. she was transported here stable, with no significant changes. she ultimately upon arrival here was unchanged in that she was not responding appropriately. she would have garbled speech, somewhat inappropriate at times, and unable to follow commands. no other history was able to be obtained. all pertinent history is documented within the records. physical examination also documented in the records, essentially as above.,physical examination: , heent: without any obvious signs of trauma. pupils are equal and reactive. extraocular movements are difficult to assess with her eyes closed, but she will open to voice. tms, canals are normal without any signs of hemotympanum. nasal mucosa and oropharynx are normal.,neck: nontender, full range of motion, was not examined initially, a collar was placed.,heart: regular.,lungs: clear.,chest/back/abdomen: without trauma.,skin: with multiple excoriations from scratching and itching.,neurologic: otherwise she has good sensation, withdrawals to pain. when lifting the arm, she will hold them up and draw, let them down slowly. with movement of the legs, she did straighten them back out slowly. dtrs were intact and equal bilaterally. otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,laboratory data: , ct scan of the head was negative as was cervical spine. she has a history of being on coumadin. her inr is 1.92, cbc was with a white count of 3.8, 50% neutrophils, 8% bands. cmp did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,assessment and plan: , ms. abc is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. it is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. at this time, she has some other abnormalities in her lab work and i recommend she be admitted for observation and further investigation. i have discussed this with her son, he agrees. otherwise, she has improved significantly. the patient was discussed with xyz, who will admit the patient for further evaluation and treatment.

operation performed:, ligament reconstruction and tendon interposition arthroplasty of right wrist.,description of procedure: , with the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint. using blunt dissection radial sensory nerve was dissected and retracted out of the operative field. further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium. an incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint. sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon. the radial beak of the trapezoid was then osteotomized off the head of the scaphoid. the proximal metacarpal was then fenestrated with a 4.5-mm drill bit. four fingers proximal to the flexion crease of the wrist a small incision was made over the fcr tendon and blunt dissection delivered the fcr tendon into this incision. the fcr tendon was divided and this incision was closed with 4-0 nylon sutures. attention was returned to the trapezial wound where longitudinal traction on the fcr tendon delivered the fcr tendon into the wound.,the fcr tendon was then threaded through the fenestration in the metacarpal. a bone anchor was then placed distal to the metacarpal fenestration. the fcr tendon was then pulled distally and the metacarpal reduced to an anatomic position. the fcr tendon was then sutured to the metacarpal using the previously placed bone anchor. remaining fcr tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect. the mp joint was brought into extension and the capsule closed using interrupted 3-0 tycron sutures.,attention was turned to the mcp joint where the mp joint was brought in to 15 degrees of flexion and pinned with a single 0.035 kirschner wire. the pin was cut at the level of the skin.,all incisions were closed with running 3-0 prolene subcuticular stitch.,sterile dressings were then applied. the tourniquet was deflated. the patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.

physical examination:, patient is a 46-year-old white male seen for annual physical exam and had an incidental psa elevation of 4.0. all other systems were normal.,procedures: ,sextant biopsy of the prostate.,radical prostatectomy: excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,pathology:,prostate biopsy: right lobe, negative. left lobe, small focus of adenocarcinoma, gleason's 3 + 3 in approximately 5% of the tissue.,radical prostatectomy: negative lymph nodes. prostate gland showing moderately differentiated infiltrating adenocarcinoma, gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right. tumor overall involved less than 5% of the tissue. surgical margin was reported and involved at the apex. the capsule and seminal vesicles were free.,discharge note:, patient has made good post-op recovery other than mild urgency incontinence. his post-op psa is 0.1 mg/ml.

preoperative diagnoses,1. cervical spondylosis with myelopathy.,2. herniated cervical disk, c4-c5.,postoperative diagnoses,1. cervical spondylosis with myelopathy.,2. herniated cervical disk, c4-c5.,operations performed,1. anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at c5-c6.,2. bilateral c6 nerve root decompression.,3. anterior cervical discectomy at c4-c5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4. bilateral c5 nerve root decompression.,5. anterior cervical discectomy at c3-c4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6. bilateral c4 nerve root decompression.,7. harvesting of autologous bone from the vertebral bodies.,8. grafting of allograft bone for creation of arthrodesis.,9. creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at c5-c6.,10. creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at c4-c5.,11. creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at c3-c4.,12. placement of anterior spinal instrumentation from c3 to c6 using a synthes small stature plate, using the operating microscope and microdissection technique.,indications for procedure: , this 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at c5-c6. there was a herniated disk with cord compression and radiculopathy at c4-c5. c3-c4 was the source of neck pain as documented by facet injections.,a detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels. because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at c3-c4, c4-c5, and c5-c6.,i explained the nature of this procedure in great detail including all risks and alternatives. he clearly understands and has no further questions and requests that i proceed.,procedure: ,the patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position. the methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,the left side of the neck was carefully prepped and draped in the usual sterile manner.,a transverse incision was made in the neck crease. dissection was carried down through the platysma musculature and the anterior spine was exposed. the medial borders of the longus colli muscle were dissected free from their attachments to the spine. caspar self-retaining pins were placed into the bodies of c3, c4, c5, and c6 and x-ray localization was obtained. a needle was placed in what was revealed to be the disk space at c4-c5 and an x-ray confirmed proper localization.,self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,first i removed the large amount of anterior overhanging osteophytes at c5-c6 and distracted the space. the high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,an incision was then made at c4-c5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,the retractors were then adjusted and again discectomy was performed at c3-c4 back to the posterior lips of the vertebral bodies. the operating microscope was then utilized.,working under magnification, i started at c3-c4 and began to work my way down to the posterior longitudinal ligament. the ligament was incised and the underlying dura was exposed. i worked out laterally towards the takeoff of the c4 nerve root and widely decompressed the nerve root edge of the foramen. there were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, i left them intact. however, i could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right. the microscope was angled to the left side where similar decompression was achieved.,the retractors were readjusted and attention was turned to c4-c5. i worked down through bony osteophytes and identified the posterior longitudinal ligament. the ligament was incised; and as i worked to the right of the midline, i encountered herniated disk material which was removed in a number of large pieces. the c5 root was exposed and then widely decompressed until i was flush with the pedicle and into the foramen. the root had a somewhat high takeoff but i worked to expose the axilla and widely decompressed it. again the microscope was angled to the left side where similar decompression was achieved. central decompression was achieved here where there was a moderate amount of spinal cord compression. this was removed by undercutting with 1 and 2-mm cloward punches.,attention was then turned to the c5-c6 space. here there were large osteophytes projecting posteriorly against the cord. i slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm cloward punches to widely decompress the spinal cord. this necessitated undercutting the bodies of both c5 and c6 extensively, but i was then able to achieve a good decompression of the cord. i exposed the c6 root and widely decompressed it until i was flush with the pedicle and into the foramen on the right. the microscope was angled to the left side where a similar decompression was achieved.,attention was then turned to creation of the arthrodesis. a high-speed cornerstone bur was used to decorticate the bodies of c5-c6, c4-c5 and c3-c4 to create a posterior shelf to prevent backwards graft migration. bone dust during the drilling was harvested for later use.,attention was turned to creation of the arthrodesis. using the various synthes sizers, i selected a 7-mm lordotic graft at c5-c6 and an 8-mm lordotic graft at c4-c5 and a 9-mm lordotic graft at c3-c4. each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge. i decided to use bmp in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks. the bmp sponge and the ____________ bone were then packed in the center of the allograft.,under distraction, the graft was placed at c3-c4, c4-c5, and c5-c6 as described. an x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,attention was turned to the placement of anterior spinal instrumentation. various sizes of synthes plates were selected until i decided that a 54-mm plate was appropriate. the plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush. the holes were drilled and the screws were placed. eight screws were placed with two screws at c3, two screws at c4, two screws at c5, and two screws at c6. all eight screws had good purchase. the locking screws were tightly applied. an x-ray was obtained which showed good placement of the graft, plate, and screws.,attention was turned to closure. the wound was copiously irrigated with bacitracin solution and meticulous hemostasis was obtained. a medium hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin. the wound was then carefully closed in layers. sterile dressings were applied, and the operation was terminated.,the patient tolerated the procedure well and left for the recovery room in excellent condition. the sponge and needle counts were reported as correct. there were no intraoperative complications.,specimens were sent to pathology consisting of disk material and bone and soft tissue.

chief complaint:, intractable epilepsy, here for video eeg.,history of present illness: , the patient is a 9-year-old male who has history of global developmental delay and infantile spasms. ultimately, imaging study shows an mri with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis. he has had severe global developmental delay, and is nonverbal. he can follow objects with his eyes, but has no ability to interact with his environment to any great degree. he has noted if any purposeful use of the hands. he has abnormal movements constantly, which are more choreiform and dystonic. he has spastic quadriparesis, which is variable at times. the patient is unable to sit or stand, and receives all his nutrition via g-tube.,the patient began having seizures in infancy presenting as infantile spasms. i began seeing him at 20 months of age. at that point, he had undergone workup in seattle, washington and then was seeing dr. x, child neurologist in mexico, who started vigabatrin for infantile spasms. the patient had benefit from this medication, and was doing well at that time with regard to that seizure type. he initially was on phenobarbital, which failed to give him benefit. he continued on phenobarbital; however, for a long period time thereafter. the patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, topamax, and zonegran at least briefly. upon starting lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2. over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense. it was more recently that he began having new seizure events that have not responded to higher doses of lamictal up to 15 mg/kg/day. these events manifest as tonic spells with eye deviation and posturing. mother reports flexion of the upper extremities, extension with lower extremities. during that time, he is not able to cry or say any sounds. these events last from seconds to minutes, and occur at least multiple times per week. there are times where he has none for a few days and other times where he has multiple days in a row with events. he has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout. he may vomit after these episodes, then seems to calm down. it is unclear whether this is a seizure or whether the patient is still responsive.,medications:, the patient's medications include lamictal for a total of 200 mg twice a day. it is a 150 mg tablet and 25 mg tablets. he is on zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day. he has other medications including the xopenex and atrovent.,review of systems: , at this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias. no respiratory or cardiovascular complaints. he has no change in his skills at this point.,family history: , noncontributory.,physical examination:,general: the patient is a slender male who is microcephalic. he has eeg electrodes in place and is on the video eeg at that time.,heent: his oropharynx shows no lesions.,neck: supple without adenopathy.,chest: clear to auscultation.,cardiovascular: regular rate and rhythm. no murmurs.,abdomen: benign with g-tube in place.,extremities: reveal no clubbing, cyanosis, or edema.,neurological: the patient is alert and has bilateral esotropia. he is able to fix and follow objects briefly. he is unable to reach for objects. he exhibits constant choreiform movements when excited. these are more prominent in the upper extremities and lower extremities. he has some dystonic posture with flexion of the wrist and fingers bilaterally. he also has plantar flexion at the ankles bilaterally. his cranial nerves reveal that his pupils are equal, round, and reactive to light. extraocular movements are intact other than bilateral esotropia. his face moves symmetrically. palate elevates in midline. hearing appears intact bilaterally.,motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above. he has clonus at the ankles bilaterally, and some valgus contracture of the ankles. his sensation is intact to light touch bilaterally. deep tendon reflexes are 2 to 3+ bilaterally.,impression/plan: , this is a 9-year-old male with congenital brain malformation and intractable epilepsy. he has microcephaly as well as dystonic cerebral palsy. he had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort. he is admitted for video eeg to hopefully capture both of these episodes and further clarify the seizure type or types. he will remain hospitalized for probably at least 48 hours to 72 hours. he could be discharged sooner if multiple events are captured. his medications, we will continue his current dose of zonegran and lamictal for now. both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.

preoperative diagnoses: , erythema of the right knee and leg, possible septic knee.,postoperative diagnoses:, erythema of the right knee superficial and leg, right septic knee ruled out.,indications: , mr. abc is a 52-year-old male who has had approximately eight days of erythema over his knee. he has been to multiple institutions as an outpatient for this complaint. he has had what appears to be prepatellar bursa aspirated with little to no success. he has been treated with kefzol and 1 g of rocephin one point. he also reports, in the emergency department today, an attempt was made to aspirate his actual knee joint which was unsuccessful. orthopedic surgery was consulted at this time. considering the patient's physical exam, there is a portal that would prove to be outside of the erythema that would be useful for aspiration of the knee. after discussion of risks and benefits, the patient elected to proceed with aspiration through the anterolateral portal of his knee joint.,procedure: ,the patient's right anterolateral knee area was prepped with betadine times two and a 20-gauge spinal needle was used to approach the knee joint approximately 3 cm anterior and 2 cm lateral to the superolateral pole of the patella. the 20-gauge spinal needle was inserted and entered the knee joint. approximately, 4 cc of clear yellow fluid was aspirated. the patient tolerated the procedure well.,disposition: , based upon the appearance of this synovial fluid, we have a very low clinical suspicion of a septic joint. we will send this fluid to the lab for cell count, crystal exam, as well as culture and gram stain. we will follow these results. after discussion with the emergency department staff, it appears that they tend to try to treat his erythema which appears to be cellulitis with iv antibiotics.

xyz, m.d. ,suite 123, abc avenue ,city, state 12345 ,re: xxxx, xxxx ,mr#: 0000000,dear dr. xyz: ,xxxx was seen in followup in the pediatric urology clinic. i appreciate you speaking with me while he was in clinic. he continues to have abdominal pain, and he had a diuretic renal scan, which indicates no evidence of obstruction and good differential function bilaterally. ,when i examined him, he seems to indicate that his pain is essentially in the lower abdomen in the suprapubic region; however, on actual physical examination, he seems to complain of pain through his entire right side. his parents have brought up the question of whether this could be gastrointestinal in origin and that is certainly an appropriate consideration. they also feel that since he has been on detrol, his pain levels have been somewhat worse, and so, i have given them the option of stopping the detrol initially. i think he should stay on miralax for management of his bowels. i would also suggest that he be referred to pediatric gastroenterology for evaluation. if they do not find any abnormalities from a gastrointestinal perspective, then the next step would be to endoscope his bladder and then make sure that he does not have any evidence of bladder anatomic abnormalities that is leading to this pain. ,thank you for following xxxx along with us in pediatric urology clinic. if you have any questions, please feel free to contact me. ,sincerely yours,

exam: ,ct maxillofacial for trauma.,findings: , ct examination of the maxillofacial bones was performed without contrast. coronal reconstructions were obtained for better anatomical localization.,there is normal appearance to the orbital rims. the ethmoid, sphenoid, and frontal sinuses are clear. there is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally. there is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally. the nasal bones appear intact. the zygomatic arches are intact. the temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes. the mandible and maxilla are intact. there is soft tissue swelling seen involving the right cheek.,impression:,1. mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally. there is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2. mild soft tissue swelling about the right cheek.

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

findings:,there is moderate to severe generalized neuronal loss of the cerebral hemispheres with moderate to severe ventricular enlargement and prominent csf within the subarachnoid spaces. there is confluent white matter hyperintensity in a bi-hemispherical centrum semiovale distribution extending to the lateral ventricles consistent with severe vasculopathic small vessel disease and extensive white matter ischemic changes. there is normal enhancement of the dural sinuses and cortical veins and there are no enhancing intra-axial or extraaxial mass lesions. there is a cavum velum interpositum (normal variant).,there is a linear area of t1 hypointensity becoming hyperintense on t2 images in a left para-atrial trigonal region representing either a remote lacunar infarction or prominent perivascular space.,normal basal ganglia and thalami. normal internal and external capsules. normal midbrain.,there is amorphus hyperintensity of the basis pontis consistent with vasculopathic small vessel disease. there are areas of t2 hyperintensity involving the bilateral brachium pontis (left greater than right) with no enhancement following gadolinium augmentation most compatible with areas of chronic white matter ischemic changes. the area of white matter signal alteration in the left brachium pontis is of some concern in that is has a round morphology. interval reassessment of this lesion is recommended.,there is a remote lacunar infarction of the right cerebellar hemisphere. normal left cerebellar hemisphere and vermis.,there is increased csf within the sella turcica and mild flattening of the pituitary gland but no sellar enlargement. there is elongation of the basilar artery elevating the mammary bodies but no dolichoectasia of the basilar artery.,normal flow within the carotid arteries and circle of willis.,normal calvarium, central skull base and temporal bones. there is no demonstrated calvarium metastases.,impression:,severe generalized cerebral atrophy.,extensive chronic white matter ischemic changes in a bi-hemispheric centrum semiovale distribution with involvement of the basis pontis and probable bilateral brachium pontis. the area of white matter hyperintensity in the left brachium pontis is of some concern is that it has a round morphology but no enhancement following gadolinium augmentation. interval reassessment of this lesion is recommended.,remote lacunar infarction in the right cerebellar hemisphere.,linear signal alteration of the left periatrial trigonal region representing either a prominent vascular space or,lacunar infarction.,no demonstrated calvarial metastases.

indication: , chest pain.,description of procedure: , after informed consent was obtained from the patient, the patient was brought to the cardiology procedure room where he was hooked up to continuous hemodynamic monitoring. the patient's baseline heart rate was 85 beats per minute and blood pressure was 124/90. the patient was started on a bruce protocol where he exercised for 11 minutes and 42 seconds achieving 12.8 mets. the patient's maximum blood pressure during this stress part was 148/80 and the patient achieved heart rate of 152 with no ekg changes, no chest pain.,findings:,1. normal hemodynamic response to exercise.,2. no ekg changes suggestive of ischemia.,3. no chest pain during the stress test.,4. achieved optimum mets for the exercise done and this is a normal exercise treadmill stress test.

history: , a is a young lady, who came here with a diagnosis of seizure disorder and history of henoch-schonlein purpura with persistent proteinuria. a was worked up for collagen vascular diseases and is here to find out the results. also was recommended to take 7.5 mg of mobic every day for her joint pains. she states that she continues with some joint pain and feeling tired all the time. mother states that also her seizure has continued without any control so far. she is having some studies in the next few days. she is mostly stiff on her legs, neck, and also on her hands. the rest of the review of systems is in the chart.,physical examination: , ,vital signs: temperature today is 99.2 degrees fahrenheit, weight is 45.9 kg, blood pressure is 123/59, height is 149.5 cm, and pulse is 94.,heent: she has no facial rashes, no lymphadenopathy, no alopecia, no oral ulcerations. pupils are reactive to accommodation. funduscopic examination is within normal limits.,neck: no neck masses.,chest: clear to auscultation.,heart: regular rhythm with no murmur.,abdomen: soft, nontender with no visceromegaly.,skin: no rashes today.,musculoskeletal: examination shows good range of motion with no swelling or tenderness in any of her joints of the upper extremities, but she does have minus/plus swelling of her knees with flexion contracture bilaterally on both.,laboratory data: , laboratories were not done recently, but we have some lab results from the previous evaluation that basically is negative for any collagen vascular disease, but shows some evidence of decreased calcium and vitamin d levels.,assessment: , this is a patient, who today presents with symptoms consistent with possible oligoarticular arthritis of her knees with also arthralgias and deficiency in vitamin d. she also has chronic proteinuria and seizure disorder. my recommendation is to start her on vitamin d and calcium supplements, and also increase the mobic to 50 mg, which is one of the few things she can tolerate with all the medication she is taking. we are going to refer her to physical therapy and see her back in 2 months for followup. the plan was discussed with a and her parents and they have no further questions.

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

chief complaint:, rule out obstructive sleep apnea syndrome.,sample patient is a pleasant, 61-year-old, obese, african-american male with a past medical history significant for hypertension, who presents to the outpatient clinic with complaints of loud snoring and witnessed apnea episodes by his wife for at least the past five years. he denies any gasping, choking, or coughing episodes while asleep at night. his bedtime is between 10 to 11 p.m., has no difficulty falling asleep, and is usually out of bed around 7 a.m. feeling refreshed. he has two to three episodes of nocturia per night. he denies any morning symptoms. he has mild excess daytime sleepiness manifested by dozing off during boring activities.,past medical history:, hypertension, gastritis, and low back pain.,past surgical history:, turp.,medications:, hytrin, motrin, lotensin, and zantac.,allergies:, none.,family history:, hypertension.,social history:, significant for about a 20-pack-year tobacco use, quit in 1991. no ethanol use or illicit drug use. he is married. he has one dog at home. he used to be employed at budd automotors as a die setter for about 37 to 40 years.,review of systems:, his weight has been steady over the years. neck collar size is 17½". he denies any chest pain, cough, or shortness of breath. last chest x-ray within the past year, per his report, was normal.,physical exam:, a pleasant, obese, african-american male in no apparent respiratory distress. t: 98. p: 90. rr: 20. bp: 156/90. o2 saturation: 97% on room air. ht: 5' 5". wt: 198 lb. heent: a short thick neck, low-hanging palate, enlarged scalloped tongue, narrow foreshortened pharynx, clear nares, and no jvd. cardiac: regular rate and rhythm without any adventitious sounds. chest: clear lungs bilaterally. abdomen: an obese abdomen with active bowel sounds. extremities: no cyanosis, clubbing, or edema. neurologic: non-focal.,impression:,1. probable obstructive sleep apnea syndrome.,2. hypertension.,3. obesity.,4. history of tobacco use.,plan:,1. we will schedule an overnight sleep study to evaluate obstructive sleep apnea syndrome.,2. encouraged weight loss.,3. check tsh.,4. asked not to drive and engage in any activity that could endanger himself or others while sleepy.,5. asked to return to the clinic one week after sleep the study is done.

reason for admission: , hepatic encephalopathy.,history of present illness: , the patient is a 51-year-old native american male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. he said that he was doing fine prior to that and denied having any complaints. he was sitting watching tv and he felt sleepy. so, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back. his head hit the toilet seat. then, he started having bleeding and had pain in the area with headache. he did not lose consciousness as far as he can tell. he went and woke up his sister. this happened somewhere between 10:30 and 11 p.m. his sister brought a towel and covered the laceration on the back of his head and called ems, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a ct of the head was obtained and ruled out any acute intracranial pathology. on his lab work, his ammonia was found to be markedly elevated at 106. so, he is being admitted for management of this. he denied having any abdominal pain, change in bowel habits, gi bleed, hematemesis, melena, or hematochezia. he said he has been taking his medicines, but he could not recall those. he denied having any symptoms prior to this fall. he said earlier today he also fell. he also said that this was an accidental fall caused by problem with his walker. he landed on his back at that time, but did not have any back pain afterwards.,past medical history:,1. liver cirrhosis caused by alcohol. this is per the patient.,2. he thinks he is diabetic.,3. history of intracranial hemorrhage. he said it was subdural hematoma. this was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4. he said he had a seizure back then, but he does not have seizures now.,past surgical history:,1. he has a surgery on his stomach as a child. he does not know the type.,2. surgery for a leg fracture.,3. craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,medications: , he does not remember his medications except for the lactulose and multivitamins.,allergies: , dilantin.,social history: , he lives in sacaton with his sister. he is separated from his wife who lives in coolidge. he smokes one or two cigarettes a day. denies drug abuse. he used to be a heavy drinker, quit alcohol one year ago and does not work currently.,family history:, negative for any liver disease.,review of systems:,general: denies fever or chills. he said he was in gilbert about couple of weeks ago for fever and was admitted there for two days. he does not know the details.,ent: no visual changes. no runny nose. no sore throat.,cardiovascular: no syncope, chest pain, or palpitations.,respiratory: no cough or hemoptysis. no dyspnea.,gi: no abdominal pain. no nausea or vomiting. no gi bleed. history of alcoholic liver disease.,gu: no dysuria, hematuria, frequency, or urgency.,musculoskeletal: denies any acute joint pain or swelling.,skin: no new skin rashes or itching.,cns: had a seizure many years ago with no recurrences. left-sided hemiparesis after subdural hematoma from a fight/trauma.,endocrine: he thinks he has diabetes but does not know if he is on any diabetic treatment.,physical examination:,vital signs: temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,general: the patient is lying in bed, appears comfortable, very pleasant native american male in no apparent distress.,heent: his skull has a scar on the left side from previous surgery. on the back of his head, there is a laceration, which has two staples on. it is still oozing minimally. it is tender. no other traumatic injury is noted. eyes, pupils react to light. sclerae anicteric. nostrils are normal. oral cavity is clear with no thrush or exudate.,neck: supple. trachea midline. no jvd. no thyromegaly.,lymphatics: no cervical or supraclavicular lymphadenopathy.,lungs: clear to auscultation bilaterally.,heart: normal s1 and s2. no murmurs or gallops. regular rate and rhythm.,abdomen: soft, distended, nontender. no organomegaly or masses.,lower extremities: +1 edema bilaterally. pulses strong bilaterally. no skin ulcerations noted. no erythema.,skin: several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,back: no tenderness by exam.,rectal: no masses. no abscess. no rectal fissures. guaiac was performed by me and it was negative.,neurologic: he is alert and oriented x2. he is slow to some extent in his response. no asterixis. right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness. increased tone noted in upper and lower extremities on the right compared to the left. deep tendon reflexes are +3 on the right and +2 on the left. muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity. the upper extremity is +4/5. lower extremity is 3/5. the left side has a normal strength. sensation appears to be intact. babinski is upward on the right, equivocal on the left.,psychiatric: flat affect. mood appeared to be appropriate. no active hallucinations or psychotic symptoms.,laboratory data:

procedure performed: , esophagogastroduodenoscopy performed in the emergency department.,indication: , melena, acute upper gi bleed, anemia, and history of cirrhosis and varices.,final impression,1. scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2. endoscopy following erythromycin demonstrated grade i esophageal varices. no stigmata of active bleeding. small amount of fresh blood within the hiatal hernia. no definite source of bleeding seen.,plan,1. repeat egd tomorrow morning following aggressive resuscitation and transfusion.,2. proton-pump inhibitor drip.,3. octreotide drip.,4. icu bed.,procedure details: ,prior to the procedure, physical exam was stable. during the procedure, vital signs remained within normal limits. prior to sedation, informed consent was obtained. risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks. the patient was prepped in the left lateral position. iv sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial egd. an additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin. scope tip of the olympus gastroscope was passed into the esophagus. proximal, middle, and distal thirds of the esophagus were well visualized. there was fresh blood in the esophagus, which was washed thoroughly, but no source was seen. no evidence of varices was seen. the stomach was entered. the stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden. there was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden. because of this, the gastroscope was withdrawn. the patient was given 250 mg of erythromycin in the emergency department and 30 minutes later, the scope was repassed. on the second look, the esophagus was cleared. the liquid gastric contents were cleared. there was still a moderate amount of clot burden in the stomach, but no active bleeding was seen. there was a small grade i esophageal varices, but no stigmata of bleed. there was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified. the patient was hemodynamically stable; therefore, a decision was made for a second look in the morning. the scope was withdrawn and air was suctioned. the patient tolerated the procedure well and was sent to recovery without immediate complications.

procedures:,1. right frontal craniotomy with resection of right medial frontal brain tumor.,2. stereotactic image-guided neuronavigation for resection of tumor.,3. microdissection and micro-magnification for resection of brain tumor.,anesthesia: , general via endotracheal tube.,indications for the procedure: ,the patient is a 71-year-old female with a history of left-sided weakness and headaches. she has a previous history of non-small cell carcinoma of the lung, treated 2 years ago. an mri was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor. after informed consent was obtained, the patient was brought to the operating room for surgery.,preoperative diagnoses: , medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,postoperative diagnoses: , medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,description of the procedure: , the patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube. she was positioned on the operating room table in the sugita frame with the head secured.,using the preoperative image-guided mri, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor. we marked external landmarks. then we shaved the head over the right medial frontal area. this area was then sterilely prepped and draped.,evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,a horseshoe shaped flap was based on the right and then brought across to the midline. this was opened and hemostasis obtained using raney clips. the skin flap was retracted medially. two burr holes were made and were carefully connected. one was placed right over the sinus and we carefully then removed a rectangular shaped bone flap. hemostasis was obtained. using the neuronavigation, we identified where the tumor was. the dura was then opened based on a horseshoe flap based on the medial sinus. we retracted this medially and carefully identified the brain. the brain surface was discolored and obviously irritated consistent with the tumor.,we used the stereotactic neuronavigation to identify the tumor margins.,then we used a bipolar to coagulate a thin layer of brain over the tumor. subsequently, we entered the tumor. the tumor itself was extremely hard. specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,we then carefully dissected around the tumor margins.,using the microscope, we then brought microscopic magnification and dissection into the case. we used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,then using the cavitron, we cored out the central part of the tumor. then we collapsed the tumor on itself and removed it entirely. in this fashion, microdissection and magnification resection of the tumor was carried out. we resected the entire tumor. neuronavigation was used to confirm that no further tumor residual was remained.,hemostasis was obtained using bipolar coagulation and gelfoam. we also lined the cavity with surgicel. the cavity was nicely dry and excellent hemostasis was obtained.,the dura was closed using multiple interrupted 4-0 nurolon sutures in a watertight fashion. surgicel was placed over the dural closure. the bone flap was repositioned and held in place using craniofix cranial fixators. the galea was re-approximated and the skin was closed with staples. the wound was dressed. the patient was returned to the intensive care unit. she was awake and moving extremities well. no apparent complications were noted. needle and sponge counts were listed as correct at the end of the procedure. estimated intraoperative blood loss was approximately 150 ml and none was replaced.

patient was informed by dr. abc that he does not need sleep study as per patient.,physical examination:,general: pleasant, brighter.,vital signs: 117/78, 12, 56.,abdomen: soft, nontender. bowel sounds normal.,assessment and plan:,1. constipation. milk of magnesia 30 ml daily p.r.n., dulcolax suppository twice a week p.r.n.,2. cad/angina. see cardiologist this afternoon.,call me if constipation not resolved by a.m., consider a fleet enema then as discussed.,

preoperative diagnoses: , acute subdural hematoma, right, with herniation syndrome.,postoperative diagnoses: , acute subdural hematoma, right, with herniation syndrome.,operation performed: ,right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,anesthesia: , general endotracheal.,preparation: , povidone.,indication:, this is an 83-year-old male with herniation syndrome with large subdural hematoma 100%. this procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,description of procedure: ,the patient was brought to the operating room intubated. the patient previously was given fresh frozen plasma plus recombinant activated factor vii. the patient had a roll placed on his right shoulder, head was maintained three point fixation with a mayfield headholder. the right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly. burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using midas rex drill with a b1 foot plate a free flap was turned. the dura was opened in a cruciate fashion, acute subdural hematoma was evacuated. there was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery. using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered. dura was closed with 4-0 nurolon. a subdural camino icp catheter was placed in the subdural space. bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 nurolon prior to placement of the bone flap. the wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 vicryl, subgaleal hemovac was placed, galea was closed with 2-0 vicryl, and scalp with staples. icp monitor and the hemovac were sutured in place with 2-0 vicryl. the patient was taken out of the head holder, a sterile dressing placed. the head was wrapped. the patient was taken directly to icu, still intubated in guarded condition. brain was nicely soft and pulsatile. at the termination of the procedure, no significant contusion of the brain was identified. final sponge and needle counts are correct. estimated blood loss 400 cc.

preoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,postoperative diagnoses,1. herniated nucleus pulposus c2-c3.,2. spinal stenosis c3-c4.,procedures,1. anterior cervical discectomy, c3-c4, c2-c3.,2. anterior cervical fusion, c2-c3, c3-c4.,3. removal of old instrumentation, c4-c5.,4. fusion c3-c4 and c2-c3 with instrumentation using abc plates.,procedure in detail: , the patient was placed in the supine position. the neck was prepped and draped in the usual fashion for anterior cervical discectomy. a high incision was made to allow access to c2-c3. skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially. this exposed the vertebral bodies of c2-c3 and c4-c5 which was bridged by a plate. we placed in self-retaining retractors. with the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of c2, c3, c4, and c5. after having done this, we used the all-purpose instrumentation to remove the instrumentation at c4-c5, we could see that fusion at c4-c5 was solid.,we next proceeded with the discectomy at c2-c3 and c3-c4 with disc removal. in a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit. it was obvious that the c3-c4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis. with the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at c2-c3 and c3-c4. we then placed the abc 55-mm plate from c2 down to c4. these were secured with 16-mm titanium screws after excellent purchase. we took an x-ray which showed excellent position of the plate, the screws, and the graft themselves. the next step was to irrigate the wound copiously with saline and bacitracin solution and s jackson-pratt drain was placed in the prevertebral space and brought out through a separate incision. the wound was closed with 2-0 vicryl for subcutaneous tissues and steri-strips used to close the skin. blood loss was about 50 ml. no complication of the surgery. needle count, sponge count, cottonoid count was correct.,the operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb. at the time of surgery, he had total collapse of the c2, c3, and c4 disc with osteophyte formation. at both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain. he does have degenerative changes at c5-c6, c6-c7, c7-t1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.

subjective: , this patient presents to the office today because he has not been feeling well. he was in for a complete physical on 05/02/2008. according to the chart, the patient gives a history of feeling bad for about two weeks. at first he thought it was stress and anxiety and then he became worried it was something else. he says he is having a lot of palpitations. he gets a fluttering feeling in his chest. he has been very tired over two weeks as well. his job has been really getting to him. he has been feeling nervous and anxious. it seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. these symptoms are not triggered by exertion. he had similar symptoms about 9 or 10 years ago. at that time he went through a full workup. everything ended up being negative and they gave him something that he took for his nerves and he says that helped. unfortunately, he does not remember what it was. also over the last three days he has had some intestinal problems. he has had some intermittent nausea and his stools have been loose. he has been having some really funny green color to his bowel movements. there has been no blood in the stool. he is not having any abdominal pain, just some nausea. he does not have much of an appetite. he is a nonsmoker.,objective: , his weight today is 168.4 pounds, blood pressure 142/76, temperature 97.7, pulse 68, and respirations 16. general exam: the patient is nontoxic and in no acute distress. there is no labored breathing. psychiatric: he is alert and oriented times 3. ears: tympanic membranes pearly gray bilaterally. mouth: no erythema, ulcers, vesicles, or exudate noted. eyes: pupils equal, round, and reactive to light bilaterally. neck is supple. no lymphadenopathy. lungs: clear to auscultation. no rales, rhonchi, or wheezing. cardiac: regular rate and rhythm without murmur. extremities: no edema, cyanosis, or clubbing.,assessment: ,1. palpitations, possibly related to anxiety.,2. fatigue.,3. loose stools with some green color and also some nausea. there has been no vomiting, possibly a touch of gastroenteritis going on here.,plan: , the patient admits he has been putting this off now for about two weeks. he says his work is definitely contributing to some of his symptoms and he feels stressed. he is leaving for a vacation very soon. unfortunately, he is actually leaving wednesday for xyz, which puts us into a bit of a bind in terms of doing testing on him. my overall opinion is he has some anxiety related issues and he may also have a touch of gastroenteritis. a 12-lead ekg was performed on him in the office today. this ekg was compared with the previous ekg contained in the chart from 2006 and i see that these ekgs look very similar with no significant changes noted, which is definitely a good news. i am going to send him to the lab from our office to get the following tests done: comprehensive metabolic profile, cbc, urinalysis with reflex to culture and we will also get a chest x-ray. tomorrow morning i will manage to schedule him for an exercise stress test at bad axe hospital. we were able to squeeze him in. his appointment is at 8:15 in the morning. he is going to have the stress test done in the morning and he will come back to the office in the afternoon for recheck. i am not going to be here so he is going to see dr. x. dr. x should hopefully be able to call over and speak with the physician who attended the stress test and get a preliminary result before he leaves for xyz. certainly, if something comes up we may need to postpone his trip. we petitioned his medical records from his former physician and with luck we will be able to find out what medication he was on about nine or ten years ago. in the meantime i have given him ativan 0.5 mg one tablet two to three times a day as needed for anxiety. i talked about ativan, how it works. i talked about the side effects. i told him to use it only as needed and we can see how he is doing tomorrow when he comes back for his recheck. i took him off of work today and tomorrow so he could rest.

preoperative diagnosis: , extremely large basal cell carcinoma, right lower lid.,postoperative diagnosis:, extremely large basal cell carcinoma, right lower lid.,title of operation: , excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,procedure: , the patient was brought into the operating room and prepped and draped in usual fashion. xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid. a frontal nerve block was also given on the right upper lid. the anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect. the area was marked with a marking pen with margins of 3 to 4 mm, and a #15 bard-parker blade was used to make an incision at the nasal and temporal margins of the lesion.,the incision was carried inferiorly, and using a steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly. the specimen was then marked and sent to pathology for frozen section. bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the bard-parker blade in the entire length of the upper lid. the incision reached the orbicularis, and steven scissors were used to separate the tarsus from the underlying orbicularis. vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly. it was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 vicryl sutures nasally, temporally, and inferiorly.,the defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region. the defect was closed with interrupted 5-0 prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures. the upper border of the graft was attached to the upper lid after incision was made in the gray line with a superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied. the patient tolerated the procedure well and was sent to recovery room in good condition.

procedure in detail:, after appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table. induction of general anesthesia via endotracheal intubation was then accomplished without difficulty. the patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun. a wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus. the 4 rectus muscles were looped and isolated using 2-0 silk suture. the retinal periphery was then inspected via indirect ophthalmoscopy.

preoperative diagnosis: ,pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,postoperative diagnosis: , pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,procedure: , primary low segment cesarean section. the patient was placed in the supine position under spinal anesthesia with a foley catheter in place and she was prepped and draped in the usual manner. a low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia. bleeding points were snapped and coagulated along the way. the fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles. these were divided in the midline revealing the peritoneum, which was opened vertically. the uterus was in mid position. the bladder flap was incised elliptically and reflected caudad. a low transverse hysterotomy incision was then constructed and extended bluntly. amniotomy revealed clear amniotic fluid. a live born vigorous male infant was then delivered from the right occiput transverse position. the infant breathed and cried spontaneously. the nares and pharynx were suctioned. the umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team. cord blood samples were obtained. the placenta was manually removed and the uterus was eventrated for closure. the edges of the uterine incision were grasped with pennington clamps and closure was carried out in standard two-layer technique using 0 vicryl suture with the second layer imbricating the first. hemostasis was completed with an additional figure-of-eight suture of 0 vicryl. the cornual sac and gutters were irrigated. the uterus was returned to the abdominal cavity. the adnexa were inspected and were normal. the abdomen was then closed in layers. fascia was closed with running 0 vicryl sutures, subcutaneous tissue with running 3-0 plain catgut, and skin with 3-0 monocryl subcuticular suture and steri-strips. blood loss was estimated at 700 ml. all counts were correct.,the patient tolerated the procedure well and left the operating room in excellent condition.

s - ,an 83-year-old diabetic female presents today stating that she would like diabetic foot care.,o - ,on examination, the lateral aspect of her left great toenail is deeply ingrown. her toenails are thick and opaque. vibratory sensation appears to be intact. dorsal pedal pulses are 1/4. there is no hair growth seen on her toes, feet or lower legs. her feet are warm to the touch. all of her toenails are hypertrophic, opaque, elongated and discolored.,a - ,1. onychocryptosis.,

cc:, difficulty with word finding.,hx: ,this 27y/o rhf experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. she denied any associated dysphagia, diplopia, numbness or weakness of her extremities. she went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. she also awoke with a headache (ha) and mild neck stiffness. she took a shower and her ha and neck stiffness resolved. throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. that evening, she began to experience numbness and weakness in the lower right face. she felt like there was a "rubber-band" wrapped around her tongue.,for 3 weeks prior to presentation, she experienced transient episodes of a "boomerang" shaped field cut in the left eye. the episodes were not associated with any other symptoms. one week prior to presentation, she went to a local er for menorrhagia. she had just resumed taking oral birth control pills one week prior to the er visit after having stopped their use for several months. local evaluation included an unremarkable carotid duplex scan. however, a hct with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. an mri brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. eeg reportedly showed diffuse slowing. crp was reportedly "too high" to calibrate.,meds:, ortho-novum 7-7-7 (started 2/3/96), and asa (started 2/20/96).,pmh:, 1)ventral hernia repair 10 years ago, 2)mild "concussion" suffered during a mva; without loss of consciousness, 5/93, 3) anxiety disorder, 4) one childbirth.,fhx: ,she did not know her father and was not in contact with her mother.,shx:, lives with boyfriend. smokes one pack of cigarettes every three days and has done so for 10 years. consumes 6 bottles of beers, one day a week. unemployed and formerly worked at an herbicide plant.,exam: ,bp150/79, hr77, rr22, 37.4c.,ms: a&o to person, place and time. speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. comprehension, naming and reading were intact. she was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. she had no difficulty with calculation.,cn: vfftc, pupils 5/5 decreasing to 3/3. eom intact. no papilledema or hemorrhages seen on fundoscopy. no rapd or ino. there was right lower facial weakness. facial sensation was intact, bilaterally. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: no deficits.,coord/station/gait: unremarkable.,reflexes 2/2 throughout. plantar responses were flexor, bilaterally.,gen exam: unremarkable.,course:, crp 1.2 (elevated), esr 10, rf 20, ana 1:40, anca <1:40, tsh 2.0, ft4 1.73, anticardiolipin antibody igm 10.8gpl units (normal <10.9), anticardiolipin antibody igg 14.8gpl (normal<22.9), ssa and ssb were normal. urine beta-hcg pregnancy and drug screen were negative. ekg, cxr and ua were negative.,mri brain, 2/21/96 revealed increased signal on t2 imaging in the periventricular white matter region of the right hemisphere. in addition, there were subtle t2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local mri can. in addition, special flair imaging showed increased signal in the right frontal region consistent with ischemia.,she underwent cerebral angiography on 2/22/96. this revealed decreased flow and vessel narrowing the candelabra branches of the rmca supplying the right frontal lobe. these changes corresponded to the areas of ischemic changes seen on mri. there was also segmental narrowing of the caliber of the vessels in the circle of willis. there was a small aneurysm at the origin of the lpca. there was narrowing in the supraclinoid portion of the rica and the proximal m1 and a1 segments. the study was highly suggestive of vasculitis.,2/23/96, neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. neuropsychologic testing the same day revealed slight impairment of complex attention only. she was started on prednisone 60mg qd and tagamet 400mg qhs.,on 2/26/96, she underwent a right frontal brain biopsy. pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. initial hct was unremarkable. an eeg was consistent with a focal lesion in the left hemisphere. however, a 2/28/96 mri brain scan revealed new increased signal on t2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. this was felt consistent with vasculitis.,she began q2month cycles of cytoxan (1,575mg iv on 2/29/96. she became pregnant after her 4th cycle of cytoxan, despite warnings to the contrary. after extensive discussions with ob/gyn it was recommended she abort the pregnancy. she underwent neuropsychologic testing which revealed no significant cognitive deficits. she later agreed to the abortion. she has undergone 9 cycles of cytoxan ( one cycle every 2 months) as of 4/97. she had complained of one episode of paresthesias of the lue in 1/97. mri then showed no new signs ischemia.

preoperative diagnosis: , severe neurologic or neurogenic scoliosis.,postoperative diagnosis: , severe neurologic or neurogenic scoliosis.,procedures: ,1. anterior spine fusion from t11-l3.,2. posterior spine fusion from t3-l5.,3. posterior spine segmental instrumentation from t3-l5, placement of morcellized autograft and allograft.,estimated blood loss: , 500 ml.,findings: , the patient was found to have a severe scoliosis. this was found to be moderately corrected. hardware was found to be in good positions on ap and lateral projections using fluoroscopy.,indications: , the patient has a history of severe neurogenic scoliosis. he was indicated for anterior and posterior spinal fusion to allow for correction of the curvature as well as prevention of further progression. risks and benefits were discussed at length with the family over many visits. they wished to proceed.,procedure:, the patient was brought to the operating room and placed on the operating table in the supine position. general anesthesia was induced without incident. he was given a weight-adjusted dose of antibiotics. appropriate lines were then placed. he had a neuromonitoring performed as well.,he was then initially placed in the lateral decubitus position with his left side down and right side up. an oblique incision was then made over the flank overlying the 10th rib. underlying soft tissues were incised down at the skin incision. the rib was then identified and subperiosteal dissection was performed. the rib was then removed and used for autograft placement later.,the underlying pleura was then split longitudinally. this allowed for entry into the pleural space. the lung was then packed superiorly with wet lap. the diaphragm was then identified and this was split to allow for access to the thoracolumbar spine.,once the spine was achieved, subperiosteal dissection was performed over the visualized vertebral bodies. this required cauterization of the segmental vessels. once the subperiosteal dissection was performed to the posterior and anterior extents possible, the diskectomies were performed. these were performed from t11-l3. this was over 5 levels. disks and endplates were then removed. once this was performed, morcellized rib autograft was placed into the spaces. the table had been previously bent to allow for easier access of the spine. this was then straightened to allow for compression and some correction of the curvature.,the diaphragm was then repaired as was the pleura overlying the thoracic cavity. the ribs were held together with #1 vicryl sutures. muscle layers were then repaired using a running #2-0 pds sutures and the skin was closed using running inverted #2-0 pds suture as well. skin was closed as needed with running #4-0 monocryl. this was dressed with xeroform dry sterile dressings and tape.,the patient was then rotated into a prone position. the spine was prepped and draped in a standard fashion.,longitudinal incision was made from t2-l5. the underlying soft tissues were incised down at the skin incision. electrocautery was then used to maintain hemostasis. the spinous processes were then identified and the overlying apophyses were split. this allowed for subperiosteal dissection over the spinous processes, lamina, facet joints, and transverse processes. once this was completed, the c-arm was brought in, which allowed for easy placement of screws in the lumbar spine. these were placed at l4 and l5. the interspaces between the spinous processes were then cleared of soft tissue and ligamentum flavum. this was done using a rongeur as well as a kerrison rongeur. spinous processes were then harvested for morcellized autograft.,once all the interspaces were prepared, songer wires were then passed. these were placed from l3-t3.,once the wires were placed, a unit rod was then positioned. this was secured initially at the screws distally on both the left and right side. the wires were then tightened in sequence from the superior extent to the inferior extent, first on the left-sided spine where i was operating and then on the right side spine. this allowed for excellent correction of the scoliotic curvature.,decortication was then performed and placement of a morcellized autograft and allograft was then performed after thoroughly irrigating the wound with 4 liters of normal saline mixed with bacitracin. this was done using pulsed lavage.,the wound was then closed in layers. the deep fascia was closed using running #1 pds suture, subcutaneous tissue was closed using running inverted #2-0 pds suture, the skin was closed using #4-0 monocryl as needed. the wound was then dressed with steri-strips, xeroform dry sterile dressings, and tape. the patient was awakened from anesthesia and taken to the intensive care unit in stable condition. all instrument, sponge, and needle counts were correct at the end of the case.,the patient will be managed in the icu and then on the floor as indicated.

subjective: , the patient states that she feels better. she is on iv amiodarone, the dosage pattern is appropriate for ventricular tachycardia. researching the available records, i find only an ems verbal statement that tachycardia of wide complex was seen. there is no strip for me to review all available ekg tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,the patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at abc medical center. the aortic stenosis was secondary to a congenital bicuspid valve, by her description. she states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition. she has not had any decline in her postoperative period of her tolerance to exertion.,the patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days. last night, she had a prolonged episode for which she contacted ems. her medications at home had been uninterrupted and without change from those listed, being toprol-xl 100 mg q.a.m., dyazide 25/37.5 mg, nexium 40 mg, all taken once a day. she has been maintaining her crestor and zetia at 20 and 10 mg respectively. she states that she has been taking her aspirin at 325 mg q.a.m. she remains on zyrtec 10 mg q.a.m. her only allergy is listed to latex.,objective:,vital signs: temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60. the patient shows a normal sinus rhythm on the telemetry monitor with an occasional pac.,general: she is alert and in no apparent distress.,heent: eyes: eomi. perrla. sclerae nonicteric. no lesions of lids, lashes, brows, or conjunctivae noted. funduscopic examination unremarkable. ears: normal set, shape, tms, canals and hearing. nose and sinuses: negative. mouth, tongue, teeth, and throat: negative except for dental work.,neck: supple and pain free without bruit, jvd, adenopathy or thyroid abnormality.,chest: lungs are clear bilaterally to auscultation. the incision is well healed and without evidence of significant cellulitis.,heart: shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub. there is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,abdomen: soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,extremities: show no evidence of dvt, acute arthritis, cellulitis or pedal edema.,neurologic: nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function. gait and station were not tested.,mental status: shows the patient to be alert, coherent with full capacity for decision making.,back: negative to inspection or percussion.,laboratory data: , shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000. inr 1.0. electrolytes are normal with exception potassium 3.3. gfr is decreased at 50 with creatinine of 1.1. glucose was 119. magnesium was 2.3. phosphorus 3.8. calcium was slightly low at 7.8. the patient has had ionized calcium checked at munson that was normal at 4.5 prior to her discharge. troponin is negative x2 from 2100 and repeat at 07:32. this morning, her bnp was 163 at admission. her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion. her current ekg tracing from 05:42 shows a sinus bradycardia with wolff-parkinson white pattern, a rate of 58 beats per minute, and a corrected qt interval of 557 milliseconds. her pr interval was 0.12.,we received a call from munson medical center that a bed had been arranged for the patient. i contacted dr. varner and we reviewed the patient's managed to this point. all combined impression is that the patient was likely to not have had actual ventricular tachycardia. this is based on her ep study from october showing her to be non-inducible. in addition, she had a cardiac catheterization that showed no evidence of coronary artery disease. what is most likely that the patient has postoperative atrial fibrillation. her wpw may have degenerated into a ventricular tachycardia, but this is unlikely. at this point, we will convert the patient from iv amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period. i will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated. dr. varner will be making arrangements for an outpatient holter monitor and further followup post-discharge.,impression:,1. atrial fibrillation with rapid ventricular response.,2. wolff-parkinson white syndrome.,3. recent aortic valve replacement with bioprosthetic medtronic valve.,4. hyperlipidemia.

preoperative diagnosis: ,oropharyngeal foreign body.,postoperative diagnoses:,1. foreign body, left vallecula at the base of the tongue.,2. airway is patent and stable.,procedure performed: , flexible nasal laryngoscopy.,anesthesia:, ______ with viscous lidocaine nasal spray.,indications: , the patient is a 39-year-old caucasian male who presented to abcd general hospital emergency department with acute onset of odynophagia and globus sensation. the patient stated his symptoms began around mid night after returning home _________ ingesting some chicken. the patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success. the patient subsequently was seen in the emergency department where it was discovered that the patient had a left vallecular foreign body. department of otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,procedure: , after verbal informed consent was obtained, the patient was placed in the upright position. the fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris. there was visualized some bilateral caudal spurring of the septum. the turbinates were within normal limits. there was some posterior nasoseptal deviation to the left. the nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity. the nasal mucous membranes were pink and moist. there was no evidence of mass, ulceration, lesion, or obstruction.,the scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally. there was evidence of some mild erythema in the right fossa rosenmüller. there was no evidence of mass lesion or ulceration in this area, however. the eustachian tubes were patent without obstruction. the scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized. there was evidence of a 1.5 cm left vallecular white foreign body. the rest of the oropharynx was without abnormality. the epiglottis was within normal limits and was noted to be omega in shape. there was no edema or erythema to the epiglottis. the scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords. there was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords. the laryngeal surface of the epiglottis was within normal limits. there was no evidence of mass lesion or nodularity of the vocal cords. the patient was asked to valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion. the patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam. the glottic aperture was completely patent with inspiration. the anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits. the scope was then removed without difficulty. the patient tolerated the procedure well and remained in stable condition.,findings:,1. a 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region. there is no evidence of supraglottic or piriform sinuses foreign body.,2. mild erythema of the right nasopharynx in the region of the fossa rosenmüller. no mass is appreciated at this time.,plan:, the patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m. airway precautions were instituted. the patient currently remained in stable condition.

discharge diagnoses,1. multiple extensive subcutaneous abscesses, right thigh.,2. massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.,procedures performed,1. on 03/05/08, by dr. x, was massive debridement of soft tissue, right lateral thigh and hip.,2. soft tissue debridement on 03/16/08 of right thigh and hip by dr. x.,3. split thickness skin graft to right thigh and right hip massive open wound on 04/01/08 by dr. y.,reason for admission: , the patient is a 62-year-old male with a history of drug use. he had a history of injection of heroin into his bilateral thighs. unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. decision was made to do a radical excision and then it is followed by reconstruction.,hospital course: ,the patient was admitted on 03/05/08 by dr. x. he was taken to the operating room. he underwent a massive resection of multiple subcutaneous abscesses, heroin remnants, which left massive huge open wounds to his right thigh and hip. this led to a prolonged hospital course. the patient initially was treated with local wound care. he was treated with broad spectrum antibiotics. he ended up growing out different species of clostridium. infectious disease consult was obtained from dr. z. he assisted in further antibiotic coverage throughout the rest of his hospitalization. the patient also had significant hypoalbuminemia, decreased nutrition. given his large wounds, he did end up getting a feeding tube placement, and prior to grafting, he received significant feeding tube supplementation to help achieve adequate nutrition for healing. the patient had this superior area what appeared to be further necrotic, infected soft tissue. he went back to the or on 03/16/08 and further resection done by dr. x. after this, his wound appeared to be free of infection. he is treated with a wound vac. he slowly, but progressively had significant progress in his wound. i went from a very poor-looking wound to a red granulated wound throughout its majority. he was thought ready for skin grafting. note that the patient had serial ultrasounds given his high risk of dvt from this massive wound and need for decreased activity. these were negative. he was treated with scds to help decrease his risk. on 04/01/08, the patient was taken to the operating room, was thought to have an adequate ________ grafting. he underwent skin grafting to his right thigh and hip massive open wound. donor sites were truncated. postoperatively, the patient ended up with a vast majority of skin graft taking. to unable to take, he was kept on iv antibiotics, strict bed rest, and limited range of motion of his hip. he is continued on vac dressing. graft progressively improved with this therapy. had another ultrasound, which was negative for dvt. the patient was mobilized up out of his bed. infectious disease recommendations were obtained. plan was to complete additional 10 days of antibiotics at discharge. this will be oral antibiotics. i would monitor his left side, which has significantly decreased inflammation and irritation or infection given the antibiotic coverage. so, decision was not made to excise this, but instead monitor. by 04/11/08, his graft looked good. it was pink and filling in. he looked stable for discharge. the patient was discharged to home.,discharge instructions: , discharge to home.,condition: , stable.,antibiotic augmentin xr script was written. he is okay to shower. donor site and graft site dressing instruction orders were given for home health and the patient. his followup was arranged with dr. x and myself.

operation: , insertion of a #8 shiley tracheostomy tube.,anesthesia: , general endotracheal anesthesia.,operative procedure in detail: , after obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.,next, a #10-blade scalpel was used to make an incision approximately 1 fingerbreadth above the sternal notch. dissection was carried down using bovie electrocautery to the level of the trachea. the 2nd tracheal ring was identified. next, a #11-blade scalpel was used to make a trap door in the trachea. the endotracheal tube was backed out. a #8 shiley tracheostomy tube was inserted, and tidal co2 was confirmed when it was connected to the circuit. we then secured it in place using 0 silk suture. a sterile dressing was applied. the patient tolerated the procedure well.

preoperative diagnosis: , right flank subcutaneous mass.,postoperative diagnosis: , right flank subcutaneous mass.,procedure performed: , excision of soft tissue mass on the right flank.,anesthesia: , sedation with local.,indications for procedure:, this 54-year-old male was evaluated in the office with a large right flank mass. he would like to have this removed.,description of procedure:, consent was obtained after all risks and benefits were described. the patient was brought back into the operating room. the aforementioned anesthesia was given. once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion. with the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank. then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass. the incision was extended down using electrocautery. the excision then had a allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle. the mass was sent off to pathology for investigation. hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed vicryl suture in a running subcuticular fashion. the patient's wound was cleaned. steri-strips were placed and sterile dressings were placed on top of this. the patient tolerated the procedure well and will reevaluate in the office in one week's time.

history of present illness: , this is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. the patient also reports a 15-pound weight loss. he denies fever, chills and sweats. he denies cough and diarrhea. he has mild anorexia.,past medical history:, essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. he had a recent ppd which was negative in august 1994.,medications: , none.,allergies: , no known drug allergies.,social history: , he occasionally drinks and is a nonsmoker. the patient participated in homosexual activity in haiti during 1982 which he described as "very active." denies intravenous drug use. the patient is currently employed.,family history:, unremarkable.,physical examination:,general: this is a thin, black cachectic man speaking in full sentences with oxygen.,vital signs: blood pressure 96/56, heart rate 120. no change with orthostatics. temperature 101.6 degrees fahrenheit. respirations 30.,heent: funduscopic examination normal. he has oral thrush.,lymph: he has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,neck: no goiter, no jugular venous distention.,chest: bilateral basilar crackles, and egophony at the right and left middle lung fields.,heart: regular rate and rhythm, no murmur, rub or gallop.,abdomen: soft and nontender.,genitourinary: normal.,rectal: unremarkable.,skin: the patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender. he has very pale palms., ,laboratory and x-ray data: , sodium 133, potassium 5.3, bun 29, creatinine 1.8. hemoglobin 14, white count 7100, platelet count 515. total protein 10, albumin 3.1, ast 131, alt 31. urinalysis shows 1+ protein, trace blood. total bilirubin 2.4, direct bilirubin 0.1. arterial blood gases: ph 7.46, pc02 32, p02 46 on room air. electrocardiogram shows normal sinus rhythm. chest x-ray shows bilateral alveolar and interstitial infiltrates.,impression:,1. bilateral pneumonia; suspect atypical pneumonia, rule out pneumocystis carinii pneumonia and tuberculosis.,2. thrush.,3. elevated unconjugated bilirubins.,4. hepatitis.,5. elevated globulin fraction.,6. renal insufficiency.,7. subcutaneous nodules.,8. risky sexual behavior in 1982 in haiti.,plan:,1. induced sputum, rule out pneumocystis carinii pneumonia and tuberculosis.,2. begin intravenous bactrim and erythromycin.,3. begin prednisone.,4. oxygen.,5. nystatin swish and swallow.,6. dermatologic biopsy of lesions.,7. check hiv and rpr.,8. administer pneumovax, tetanus shot and heptavax if indicated.

identification of patient: , abcd is an 8-year-old hispanic male currently in the second grade.,chief complaint/history of present illness: , abcd presents to this visit with his mother, xyz, and her significant other, pqr. circumstances leading to this admission: in the past, abcd has been diagnosed and treated for adhd, combined type, and has been on concerta 54 mg one p.o. q.8h. since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper. abcd is also complaining of headaches when he takes the medication. mother reports that on the weekends he is off the medication. she does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, "it's an accident." she sees him as impulsive on the weekends, but is not sure if this just isn't "all boy.",mother reports abcd has been on medication since kindergarten. currently, the teachers say he is able to pay attention and he is well behaved in school. prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,he had a psychological evaluation done on 07/16/06 by dr. x, in which he was diagnosed with adhd, combined type; odd; rule out depressive disorder, nos; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct. he also has seen xyz, lcsw, in the past for outpatient therapy.,abcd's mother, a, as well as her significant other, r, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,review of systems:,sleep: as stated before, he is having much difficulty on a consistent basis falling asleep. it is 12:00 to 1:00 a.m. before he falls to sleep. when he was on the 36 mg of concerta, he was able to fall asleep without difficulty. on the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,appetite: he will eat breakfast and supper, but not much lunch, if any at all. he has not lost weight that mother is aware of, nor is he getting more sick than normal.,mood control: mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior. the only exception to this is he gets in occasional fights with his sisters. abcd denies visual or auditory hallucinations or racing thoughts. he reports his thoughts are sometimes bad because he says sometimes he thinks of the "s" word.,energy: mother reports a lot of energy.,pain: abcd denies any pain in his body.,suicidal or homicidal thoughts: he denies suicidal thoughts or plan to hurt himself or anyone else.,past treatment and/or medications:,abcd was originally tried on ritalin in kindergarten, and he has been on concerta since 07/14/06. he has received outpatient therapy from xyz, lcsw. he is currently not in outpatient therapy.,family psychiatric history:,mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar. she reports she has significant moodiness episodes and believes in the past she has had a manic episode. she is currently not on medication. she does not know of anyone else in her family, with the exception of she said her father's behavior was "weird." biological father's side of the family, mother reports father was very impulsive. he had anger issues. he had drug and alcohol issues. he was in jail for three years for risky behavior. there was also domestic violence when mother was married to father.,family and social history:,biological mother and father were married for five years. they divorced when abcd was 2-1/2 years of age. currently, father has been deported back to mexico. he last saw abcd in march 2006 for one day when they went down to aaaa. he does call on special holidays and his birthday. contact is brief, but so far has been consistent. mother is currently seeing r, a significant other, and has been seeing him for the last seven months. abcd had a good relationship with r. abcd has an older sister, m, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, s, age 7, who mother describes as "all wisdom.",pregnancy:, mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while abcd was in utero. she did not use drugs or alcohol while she was pregnant.,developmental milestones:, developmental milestones were all met on time, although abcd has had speech therapy since he was young.,physical abuse:, mother and abcd deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,discipline problems:, mother reports abcd was a very cuddly infant and could sleep well. as a toddler, he was all over the place, climbing and always busy. elementary school: in kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen. abcd has no history of fire setting or abuse to animals. he does not lie more than other kids his age and he does not have any issues with stealing.,past drug and alcohol history:, noncontributory.,medical status and history:, abcd has no known drug allergies. he has no history of heart murmur, heart defect of other heart problems. no history of asthma, seizures or head injuries. he no medical diagnosis and he has ever spent an overnight in a medical hospital.,school:, when i asked abcd whether he likes school, he stated, "no." his grades are okay, per mother. he does have an iep for the adhd, but she does not believe he has a learning disability. behavior problems: he currently is not having any behavior problems in the school. he reports he does not get along with his teachers because they tell him what to do. strengths: he reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,relationships:, he reports he has best friends. he named two, d and b, and he does have a friend that is a girl named kim. when asked if church or god were important to him, he stated, "god is." he is in a roman catholic family and that is an important aspect of his life.,work history:, in the home, he has chores of taking out the trash.,legal:, he has not been involved in the legal system.,support systems:, when asked if he feels safe in his home, he stated, "yes." when asked who he talks to if he is hurt or upset, he stated, "mom." (at first, he said video games, but then he said mom).,talents and gifts:, he is good at basketball, video games, and reading books.,mental status exam:, this was a very long appointment, approximately two hours in length, due to mother and significant other had many questions. abcd kept himself occupied throughout and was very well behaved throughout the session. he had some significant memory responses in that he remembered the last holiday was martin luther king day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes. distractibility and attention: he, at times, was very mildly distracted, but otherwise did not appear hyperactive. his judgment was adequate. when asked what he would do if there was a fire in his house, he said, "get out!" insight was poor to adequate. fund of information was good. when asked who the president was, he said, "george washington." intelligence is probably average to above average. speech was normal. he had some difficulty with abstract thinking. he could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle. on serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly. when given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly. appearance was casual. hygiene was good. attitude was cooperative. speech was normal. psychomotor was between normal and slightly hyperactive. orientation was x2. attention/concentration was intact. memory was intact at times and then had some memory recall problems with three words. mood was euthymic. affect was bright. he has no suicidal or homicidal/violence risks. perceptions were normal. thought process logical. thought content normal. disassociation none. sleep: he is having some insomnia. appetite/eating are decreased.,strengths and supports:, he has a strong support system in his mother, grandmother, and mother's significant other, richard. he has good health. he has shown gain from past treatment. he has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.

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

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

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

preoperative diagnoses: , multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,postoperative diagnoses: , multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,title of the operation:,1. biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2. insertion of left lateral ventriculostomy under stealth stereotactic guidance.,3. right suboccipital craniectomy and excision of tumor.,4. microtechniques for all the above.,5. stealth stereotactic guidance for all of the above and intraoperative ultrasound.,indications: , the patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago. a year ago, she was diagnosed with cranial metastases and underwent whole brain radiation. she recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair. metastatic workup does reveal multiple bone metastases, but no spinal cord compression. she had a consult with radiation-oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed. consequently, this operation is performed.,procedure in detail: , the patient underwent a planning mri scan with stealth protocol. she was brought to the operating room with fiducial still on her scalp. general endotracheal anesthesia was obtained. she was placed on the mayfield head holder and rolled into the prone position. she was well padded, secured, and so forth. the neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions. the posterior aspect of the calvarium was shaved and prepared in the usual manner with betadine soak scrub followed by betadine paint. this was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the stealth system. sterile drapes were applied and the accuracy of the system was confirmed. a biparietal incision was performed. a linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation. a biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the stealth stereotactic system. the dura was opened and reflected back to the midline. an inner hemispheric approach was used to reach the very large metastatic tumor. this was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor. the tumor was wrapped around and included the choroidal vessels. at least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region. bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled. complete removal of the tumor was confirmed by intraoperative ultrasound.,once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area. a linear incision was made just lateral to the greater occipital nerve. sharp dissection was carried down in the subcutaneous tissues and bovie electrocautery was used to reach the skull. a burr hole was placed down low using a craniotome. a craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter. it was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus. stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum. the ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining csf relieving pressure in the posterior fossa. upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,at the posterior fossa, a corticectomy was accomplished and the tumor was countered directly. the tumor, as the one above, was removed, both piecemeal and with intraoperative cavitron ultrasonic aspirator. a gross total excision of this tumor was obtained as well.,i then explored underneath the cerebellum in hopes of finding another metastasis in the cp angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,meticulous hemostasis was obtained for this wound as well.,the posterior fossa wound was then closed in layers. the dura was closed with interrupted and running mattress of 4-0 nurolon. the dura was watertight, and it was covered with blue glue. gelfoam was placed over the dural closure. then, the muscle and fascia were closed in individual layers using #0 ethibond. subcutaneous was closed with interrupted inverted 2-0 and 0 vicryl, and the skin was closed with running locking 3-0 nylon.,for the cranial incision, the ventriculostomy was brought out through a separate stab wound. the bone flap was brought on to the field. the dura was closed with running and interrupted 4-0 nurolon. at the beginning of the case, dural tack-ups had been made and these were still in place. the sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked gelfoam to take care of any small bleeding areas in the sinuses.,once the dura was closed, the bone flap was returned to the wound and held in place with the lorenz microplates. the wound was then closed in layers. the galea was closed with multiple sutures of interrupted 2-0 vicryl. the skin was closed with a running locking 3-0 nylon.,estimated blood loss for the case was more than 1 l. the patient received 2 units of packed red cells during the case as well as more than 1 l of hespan and almost 3 l of crystalloid.,nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.

preoperative diagnoses:,1. maxillary atrophy.,2. severe mandibular atrophy.,3. acquired facial deformity.,4. masticatory dysfunction.,postoperative diagnoses:,1. maxillary atrophy.,2. severe mandibular atrophy.,3. acquired facial deformity.,4. masticatory dysfunction.,procedure performed: , autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,dr. x and company accompanied the patient to or #6 at 7:30 a.m. nasal trachea intubation was performed per routine. the bilateral iliac crest harvest was first performed by dr. x and company under separate or report. once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft. then, cat scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft. subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine. surgical team scrubbed and gowned in usual fashion and the patient was draped. xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa. a primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion. release incisions were made in the posterior region of the maxilla.,a full-thickness periosteal reflexion first exposed the palatal region. the contents of the neurovascular canal from the greater palatine foramina were identified. the hard palate was directly observed. the facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine. similar features were reflected on the contralateral side. the area was re-contoured with rongeurs. the block of bone, which was formed and harvested from the left ilium was then placed and found to be stable. a surgical mallet then compressed this bone further into the region. a series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla. particulate bone was then placed around the remaining block of bone. a piece of alloderm mixed with croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block. the tissues were expanded then with a tissue metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 gore-tex. attention was brought then to the mandible. 1% xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given. a primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body. the anterior body was found to be approximately 3 mm in height. a posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved. a tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible. a similar procedure was done on the contralateral side. the tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair. a block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws. the block of bone was further re-contoured in situ. particulate bone was then injected into the posterior tunnels bilaterally. a piece of alloderm was placed over those particulate segments. the tissues were approximated for primary closure using #3-0 gore-tex suture both interrupted and horizontal mattress in form. the tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,the estimated blood loss in the harvest of the hip was 100 cc. the estimated blood loss in the intraoral procedure was 220 cc. total blood loss for the procedure 320 cc. the fluid administered 300 cc. the urine out 180. all sponges were counted encountered for as were sutures. the patient was taken to recovery at approximately 12 o'clock noon.

a colonoscope was then passed through the rectum, all the way toward the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. this was done without difficulty and the bowel preparation was good. the ileocecal valve was intubated and the distal 2 to 3 cm of terminal ileum was inspected and was normal. the colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed.,complications: , none.

chief complaint: , both pancreatic and left adrenal lesions.,history of present illness:, this 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland. the patient's history dates back to at the end of the january of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back. he noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling. he is now sleeping in an upright position. he was sent for cat scan originally of his chest. the cat scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion. he was subsequently was sent for a dedicated abdominal cat scan and mri. the cat scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma. the pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature. neoplasm could not be excluded. he was referred to us for further assessment. he denies any significant abdominal pain, any nausea or vomiting. his appetite is fine. he has had no significant changes in his bowel habits or any rectal bleeding or melena. he has undergone a colonoscopy in september of last year and was found to have three adenomatous polyps. he does have a history of frequent urination. has been followed by urologist for this. there is no family history of pancreatic cancer. there is a history of gallstone pancreatitis in the patient's sister.,past medical history:, significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,allergies: , environmental.,medications:, include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., atacand 16 mg daily, metoprolol 25 mg b.i.d., lipitor 10 mg daily, pantoprazole 40 mg daily, flomax 0.4 mg daily, detrol 4 mg daily, zyrtec 10 mg daily, advair diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,past surgical history:, he has not had any previous surgery.,family history: , his brothers had prostate cancer. father had brain cancer. heart disease in both sides of the family. has diabetes in his brother and sister.,social history:, he is a non-cigarette smoker and non-etoh user. he is single and he has no children. he works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,review of systems: , he denies any chest pain. he admits to exertional shortness of breath. he denies any gi problems as noted. has frequent urination as noted. he denies any bleeding disorders or bleeding history.,physical examination:,general: presents as an obese 60-year-old white male, who appears to be in no apparent distress.,heent: unremarkable.,neck: supple. there is no mass, adenopathy or bruit.,chest: normal excursion.,lungs: clear to auscultation and percussion.,cor: regular. there is no s3 or s4 gallop. there is no obvious murmur.,heart: there is distant heart sounds.,abdomen: obese. it is soft. it is nontender. examination was done as relatively sitting up as the patient was unable to recline. bowel sounds are present. there is no obvious mass or organomegaly.,genitalia: deferred.,rectal: deferred.,extremities: revealed about 1+ pitting edema. bilateral peripheral pulses are intact.,neurologic: without focal deficits. the patient is alert and oriented.,impression:, both left adrenal and pancreatic lesions. the adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded. given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ercp will be of no value and the likelihood is that it is too small to biopsy. we are going to review x-rays with radiology prior with the patient probably at some point will present for operative intervention. prior to that the patient will undergo an esophagogastroduodenoscopy.

preprocedure diagnosis: , complete heart block.,postprocedure diagnosis: ,complete heart block.,procedures planned and performed,1. implantation of a dual-chamber pacemaker.,2. fluoroscopic guidance for implantation of a dual-chamber pacemaker.,fluoroscopy time: , 2.6 minutes.,medications at the time of study,1. versed 2.5 mg.,2. fentanyl 150 mcg.,3. benadryl 50 mg.,clinical history: , the patient is a pleasant 80-year-old female who presented to the hospital with complete heart block. she has been referred for a pacemaker implantation.,risks and benefits: , risks, benefits, and alternatives to implantation of a dual-chamber pacemaker were discussed with the patient. the patient agreed both verbally and via written consent.,description of procedure: , the patient was transported to the cardiac catheterization laboratory in the fasting state. the region of the left deltopectoral groove was prepped and draped in the usual sterile manner. lidocaine 1% (20 ml) was administered to the area. after achieving appropriate anesthesia, percutaneous access of the left axillary vein was then performed under fluoroscopy. a guide wire was advanced into the vein. following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath. hemostasis was achieved with electrocautery. lidocaine 1% (10 ml) was then administered to the medial aspect of the incision. a pocket was then fashioned in the medial direction. using the previously placed wire, a 7-french side-arm sheath was advanced over the wire into the left axillary vein. the dilator was then removed over the wire. a second wire was then advanced into the sheath into the left axillary vein. the sheath was then removed over the top of the two wires. one wire was then pinned to the drape. using the remaining wire, a 7 french side-arm sheath was advanced back into the left axillary vein. the dilator and wire were removed. a passive pacing lead was then advanced down into the right atrium. the peel-away sheath was removed. the lead was then passed across the tricuspid valve and positioned in the apical location. adequate pacing and sensing functions were established. suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. with the remaining wire, a 7-french side-arm sheath was advanced over the wire into the axillary vein. the wire and dilating sheaths were removed. an active pacing lead was then advanced down into the right atrium. the peel-away sheath was removed. preformed j stylet was then advanced into the lead. the lead was positioned in the appendage location. lead body was then turned, and the active fix screw was fixed to the tissue. adequate pacing and sensing function were established. suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue. the pocket was then washed with antibiotic-impregnated saline. pulse generator was obtained and connected securely to the leads. the leads were then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket. the pocket was then closed with 2-0, 3-0, and 4-0 vicryl using a running mattress stitch. sponge and needle counts were correct at the end of the procedure. no acute complications were noted.,device data,1. pulse generator, manufacturer boston scientific, model # 12345, serial #1234.,2. right atrial lead, manufacturer guidant, model #12345, serial #1234.,3. right ventricular lead, manufacturer guidant, model #12345, serial #1234.,measured intraoperative data,1. right atrial lead impedance 534 ohms. p waves measured at 1.2 millivolts. pacing threshold 1.0 volt at 0.5 milliseconds.,2. right ventricular lead impedance 900 ohms. r-waves measured 6.0 millivolts. pacing threshold 1.0 volt at 0.5 milliseconds.,device settings: , ddd 60 to 130.,conclusions,1. successful implantation of a dual-chamber pacemaker with adequate pacing and sensing function.,2. no acute complications.,plan,1. the patient will be taken back to her room for continued observation. she can be dismissed in 24 hours provided no acute complications at the discretion of the primary service.,2. chest x-ray to rule out pneumothorax and verified lead position.,3. completion of the course of antibiotics.,4. home dismissal instructions provided in written format.,5. device interrogation in the morning.,6. wound check in 7 to 10 days.,7. enrollment in device clinic.

subjective: , this is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. she says her asthma has been worse over the last three months. she has been using her inhaler daily. her allergies seem to be a little bit worse as well. her husband has been hauling corn and this seems to aggravate things. she has not been taking allegra daily but when she does take it, it seems to help somewhat. she has not been taking her flonase which has helped her in the past. she also notes that in the past she was on advair but she got some vaginal irritation with that.,she had been noticing increasing symptoms of irritability and pms around her menstrual cycle. she has been more impatient around that time. says otherwise her mood is normal during the rest of the month. it usually is worse the week before her cycle and improves the day her menstrual cycle starts. menses have been regular but somewhat shorter than in the past. occasionally she will get some spotting after her cycles. she denies any hot flashes or night sweats with this. in reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. her urine has not been rechecked. she recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,review of systems: , as above. no fevers, no headaches, no shortness of breath currently. no chest pain or tightness. no abdominal pain, no heartburn, no constipation, diarrhea or dysuria. occasional stress incontinence. no muscle or joint pain. no concerns about her skin. no polyphagia, polydipsia or polyuria.,past medical history: , significant for asthma, allergic rhinitis and cervical dysplasia.,social history: , she is married. she is a nonsmoker.,medications: , proventil and allegra.,allergies: , sulfa.,objective:,vital signs: her weight is 151 pounds. blood pressure is 110/60. pulse is 72. temperature is 97.1 degrees. respirations are 20.,general: this is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress. affect is appropriate and is pleasant.,heent: normocephalic, atraumatic. tympanic membranes are clear. conjunctivae are clear. pupils are 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.,extremities: without cyanosis or edema.,skin: without abnormalities.,breasts: normal symmetrical breasts without dimpling or retraction. no nipple discharge. no masses or lesions to palpation. no axillary masses or lymphadenopathy.,genitourinary: normal external genitalia. the walls of the vaginal vault are visualized with normal pink rugae with no lesions noted. cervix is visualized without lesion. she has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault. no cervical motion tenderness. no adnexal tenderness or fullness.,assessment/plan:,1. asthma. seems to be worse than in the past. she is just using her proventil inhaler but is using it daily. we will add flovent 44 mcg two puffs p.o. b.i.d. may need to increase the dose. she did get some vaginal irritation with advair in the past but she is willing to retry that if it is necessary. may also need to consider singulair. she is to call me if she is not improving. if her shortness of breath worsens she is to call me or go into the emergency department. we will plan on following up for reevaluation in one month.,2. allergic rhinitis. we will plan on restarting allegra and flonase daily for the time being.,3. premenstrual dysphoric disorder. she may have some perimenopausal symptoms. we will start her on fluoxetine 20 mg one tablet p.o. q.d.,4. hematuria. likely this is secondary to urinary tract infection but we will repeat a ua to document clearing. she does have some frequent dysuria but is not having it currently.,5. cervical dysplasia. pap smear is taken. we will notify the patient of results. if normal we will go back to yearly pap smear. she is scheduled for screening mammogram and instructed on monthly self-breast exam techniques. recommend she get 1200 mg of calcium and 400 u of vitamin d a day.

subjective:, the patient is admitted for lung mass and also pleural effusion. the patient had a chest tube placement, which has been taken out. the patient has chronic atrial fibrillation, on anticoagulation. the patient is doing fairly well. this afternoon, she called me because heart rate was in the range of 120 to 140. the patient is lying down. she does have shortness of breath, but denies any other significant symptoms.,past medical history:, history of mastectomy, chest tube placement, and atrial fibrillation; chronic.,medications:,1. cardizem, which is changed to 60 mg p.o. t.i.d.,2. digoxin 0.25 mg daily.,3. coumadin, adjusted dose.,4. clindamycin.,physical examination,vital signs: pulse 122 and blood pressure 102/68.,lungs: air entry decreased.,heart: pmi is displaced. s1 and s2 are irregular.,abdomen: soft and nontender.,impression:,1. pulmonary disorder with lung mass.,2. pleural effusion.,3. chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,recommendations:,1. from cardiac standpoint, follow with pulmonary treatment.,2. the patient has an inr of 2.09. she is on anticoagulation. atrial fibrillation is chronic with the rate increased.,adjust the medications accordingly as above.

preoperative diagnosis: , scalp lacerations.,postoperative diagnosis: , scalp lacerations.,operation performed: , incision and drainage (i&d) with primary wound closure of scalp lacerations.,anesthesia:, get.,ebl: , minimal.,complications: , none.,drains: , none.,disposition: , vital signs stable and taken to the recovery room in a satisfactory condition.,indication for procedure: ,the patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident. the patient was taken to the operating room for an i&d of the lacerations with wound closure.,procedure in detail: ,after appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5. before the neck instrumentation was performed, the patient's lacerations to her scalp were i&d'ed and closed. it was noted that the head was significantly contaminated with blood as well as mangled. it was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair. this was shaved appropriately with shavers. once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide. once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline. no significant debris was appreciated. once this was done, staples were used to oppose the dermal edges together. the patient was subsequently dressed sterilely using bacitracin ointment, xeroform, 4x4s, and tape. the neck procedure was subsequently performed.

preoperative diagnoses:,1. lumbar osteomyelitis.,2. need for durable central intravenous access.,postoperative diagnoses:,1. lumbar osteomyelitis.,2. need for durable central intravenous access.,anesthesia:, general.,procedure:, placement of left subclavian 4-french broviac catheter.,indications: ,the patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas. the patient needs prolonged iv antibiotic therapy, but attempt at a picc line failed. she has exhausted most of her easy peripheral iv access routes and referral was made to the pediatric surgery service for broviac placement. i met with the patient's mom. with the help of a spanish interpreter, i explained the technique for broviac placement. we discussed the surgical risks and alternatives, most of which have been exhausted. all their questions have been answered, and the patient is fit for operation today.,description of operation: ,the patient came to the operating room and had an uneventful induction of general anesthesia. we conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the broviac catheter. preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed. a flexible guidewire was inserted into the central location and then a 4-french broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins. the catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines. the peel-away sheath was passed over the guidewire and then the 4-french catheter was deployed through the peel-away sheath. there was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava. the catheter insertion site was closed with one buried 5-0 monocryl stitch and the same 5-0 monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred. heparinized saline solution was used to flush the line. a sterile occlusive dressing was applied, and the line was prepared for immediate use. the patient was transported to the recovery room in good condition. there were no intraoperative complications, and her blood loss was between 5 and 10 ml during the line placement portion of the procedure.

cc: ,bilateral lower extremity numbness.,hx: ,21 y/o rhm complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. the symptoms became maximal over a 12-24 hour period and have not changed since. the symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. he noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. he denied bowel/bladder problems, or weakness or numbness elsewhere. hot showers may improve his symptoms. he has suffered no recent flu-like illness. past medical and family histories are unremarkable. he was on no medications.,exam:, unremarkable except for mild distal vibratory sensation loss in the toes (r>l).,lab:, cbc, gen screen, tsh, ft4, spe, ana were all wnl.,mri l-spine:, normal.,course:, normal exam and diminished symptoms at following visit 4/23/93.

name of procedure,1. selective coronary angiography.,2. placement of overlapping 3.0 x 18 and 3.0 x 8 mm xience stents in the proximal right coronary artery.,3. abdominal aortography.,indications: ,the patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain. thallium scan has been negative. he is undergoing angiography to determine if his symptoms are due to coronary artery disease.,narrative: ,the right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine. constant sedation was obtained using versed 1 mg and fentanyl 50 mcg. received additional versed and fentanyl during the procedure. please refer to the nurses' notes for dosages and timing.,the right femoral artery was entered and a 4-french sheath was placed. advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta. via the right judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch. the right judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed. this revealed a very high-grade lesion at the proximal right coronary artery. this catheter was exchanged for a left #4 judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,the patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed. a 6-french sheath and a right judkins guide was placed. the patient was started on bivalarudin. a bmw wire was easily placed across the lesion and into the distal right coronary artery. a 3.0 x 15 mm voyager balloon was placed and deployed at 10 atmospheres. the intermediate result was improved with timi-3 flow to the terminus of the vessel. following this, a 3.0 x 18 mm xience stent was placed across the lesion and deployed at 17 atmospheres. this revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection. this was stented with a 3.0 x 8 mm xience stent deployed again at 17 atmospheres. final angiograms revealed excellent result with timi-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing. the guiding catheter was withdrawn over wire and a pigtail was placed. this was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection. the catheter was removed. the bivalarudin was stopped at the termination of procedure. a small injection of contrast given through arterial sheath and angio-seal was placed without incident.,it should also be noted that an 8-french sheath was placed in the right femoral vein. this was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,total contrast media, 205 ml, total fluoroscopy time was 7.5 minutes, x-ray dose, 2666 milligray.,hemodynamics: , rhythm was sinus throughout the procedure. aortic pressure was 170/81 mmhg.,the right coronary artery is a dominant vessel. this vessel gives rise to conus branch and two small rv free wall branches and pda and a small left ventricular branch. it should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals. in the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity. after intervention, there is timi-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow. there was approximately 10% residual stenosis at the worst part of the previous stenosis.,the left main is without disease and trifurcates into a moderate-sized ramus intermedius, the lad and the circumflex. the ramus intermedius is free of disease. the lad terminates at the lv apex and has elongated area of mild stenosis at its mid segment. this measures 25% to 30% at its worst point. the circumflex is a large caliber vessel. there is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex. distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the av groove.,the aortogram demonstrates eccentric aneurysm formation. this may represent a small retrograde dissection as well. there was some dye hang up in the wall.,impression,1. successful stenting of subtotal stenosis of the proximal coronary artery.,2. non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3. left to right collateral filling noted prior to coronary intervention.,4. small area of eccentric aneurysm formation in the abdominal aorta.

preoperative diagnosis: , antibiotic-associated diarrhea. ,postoperative diagnosis: ,antibiotic-associated diarrhea. ,operation performed: , colonoscopy with random biopsies and culture.,indications: , the patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago. she has been having difficulty since that time with intermittent diarrhea and abdominal pain. she states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes. she presents today for screening colonoscopy, based on the same.,operative course: , the risks and benefits of colonoscopy were explained to the patient in detail. she provided her consent. the morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite. she was placed in the left lateral decubitus position. in divided doses, she was given 7 mg of versed and 125 mcg of fentanyl. a digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure. this was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided. in truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure. while more medication could have been given, the patient is actually a fairly thin woman and diminutive and i was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse. in addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk. for this reason, the procedure was aborted at the level of the hepatic flexure. she was noted to have some pools of stool. this was suctioned and sent to pathology for c difficile, ova and parasites, and fecal leukocytes. additionally, random biopsies were performed of the colon itself. it is unfortunate we were unable to complete this procedure, as i would have liked to have taken biopsies of the terminal ileum. however, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, i am very suspicious of irritable bowel syndrome. the patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,plan:, she needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures. she has been given a prescription for vsl3, a probiotic, to assist with reculturing the rectum. she may also benefit from an antispasmodic and/or anxiolytic. lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.

discharge diagnoses:,1. acute respiratory failure, resolved.,2. severe bronchitis leading to acute respiratory failure, improving.,3. acute on chronic renal failure, improved.,4. severe hypertension, improved.,5. diastolic dysfunction.,x-ray on discharge did not show any congestion and pro-bnp is normal.,secondary diagnoses:,1. hyperlipidemia.,2. recent evaluation and treatment, including cardiac catheterization, which did not show any coronary artery disease.,3. remote history of carcinoma of the breast.,4. remote history of right nephrectomy.,5. allergic rhinitis.,hospital course:, this 83-year-old patient had some cold symptoms, was treated as bronchitis with antibiotics. not long after the patient returned from mexico, the patient started having progressive shortness of breath, came to the emergency room with severe bilateral wheezing and crepitations. x-rays however did not show any congestion or infiltrates and pro-bnp was within normal limits. the patient however was hypoxic and required 4l nasal cannula. she was admitted to the intensive care unit. the patient improved remarkably over the night on iv steroids and empirical iv lasix. initial swab was positive for mrsa colonization., ,discussed with infectious disease, dr. x and it was decided no treatment was required for de-colonization. the patient's breathing has improved. there is no wheezing or crepitations and o2 saturation is 91% on room air. the patient is yet to go for exercise oximetry. her main complaint is nasal congestion and she is now on steroid nasal spray. the patient was seen by cardiology, dr. z, who advised continuation of beta blockers for diastolic dysfunction. the patient has been weaned off iv steroids and is currently on oral steroids, which she will be on for seven days.,disposition: , the patient has been discharged home.,discharge medications:,1. metoprolol 25 mg p.o. b.i.d.,2. simvastatin 20 mg p.o. daily.,new medications:,1. prednisone 20 mg p.o. daily for seven days.,2. flonase nasal spray daily for 30 days.,results for oximetry pending to evaluate the patient for need for home oxygen.,follow up:, the patient will follow up with pulmonology, dr. y in one week's time and with cardiologist, dr. x in two to three weeks' time.

subjective:, the patient is keeping a food journal that she brought in. she is counting calorie points, which ranged 26 to 30 per day. she is exercising pretty regularly. she attends overeaters anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. the patient requests information on diabetic exchanges. she said she is feeling better since she has lost weight.,objective:,vital signs: the patient's weight today is 209 pounds, which is down 22 pounds since i last saw her on 06/07/2004. i praised her weight loss and her regular exercising. i looked at her food journal. i praised her record keeping. i gave her a list of the diabetic exchanges and explained them. i also gave her a food dairy sheet so that she could record exchanges. i encouraged her to continue.,assessment:, the patient seems happy with her progress and she seems to be doing well. she needs to continue.,plan:, followup is on a p.r.n. basis. she is always welcome to call or return.

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.

admitting diagnosis: , trauma/atv accident resulting in left open humerus fracture.,discharge diagnosis:, trauma/atv accident resulting in left open humerus fracture.,secondary diagnosis:, none.,history of present illness: , for complete details, please see dictated history and physical by dr. x dated july 23, 2008. briefly, the patient is a 10-year-old male who presented to the hospital emergency department following an atv accident. he was an unhelmeted passenger on atv when the driver lost control and the atv rolled over throwing the passenger and the driver approximately 5 to 10 meters. the patient denies any loss of consciousness. he was not amnestic to the event. he was taken by family members to the iredell county hospital, where he was initially evaluated. due to the extent of his injuries, he was immediately transferred to hospital emergency department for further evaluation.,hospital course: , upon arrival in the hospital emergency department, he was noted to have an open left humerus fracture. no other apparent injuries. this was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment. the left upper extremity x-ray did demonstrate an open left distal humerus fracture. the orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture. in the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture. in the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures. throughout the duration of the procedure, the patient had a palpable distal radial pulse. the orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture. a wound vac was then placed over the wound at the conclusion of the procedure. the patient tolerated this procedure well and was returned to the pediatric intensive care unit for postsurgical followup and monitoring. his diet was advanced and his pain was controlled with pain medication. the day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident. a ct of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his c-collar was removed at that point. once his c spine had been cleared and the absence of a closed head injury was confirmed. the patient was then transferred from the intensive care unit to the general floor bed. his clinical status continued to improve and on july 26, 2008, he was taken back to the operating room for removal of the wound vac and closure of his left upper extremity wound. he again tolerated this procedure well on his return to the general pediatrics floor. throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries. however, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity. moreover, the patient had no complaints of paresthesia. there was no demonstration of pallor or pain on passive motion. there was good capillary refill to the digits of the left hand. by the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well. he had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies. he was afebrile and his vital signs were stable and once cleared by orthopedics, he was deemed appropriate for discharge.,procedures during this hospitalization:,1. irrigation and debridement of open type 3 subcondylar left distal humerus fracture (july 23, 2008).,2. open reduction and internal fixation of the left supracondylar humerus fracture (july 23, 2008).,3. negative pressure wound dressing (july 23, 2008).,4. irrigation and debridement of left elbow fracture (july 26, 2008).,5. ct of the brain without contrast (july 24, 2008).,disposition: ,home with parents.,invasive lines: , none.,discharge instructions: ,the patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity. he was asked to followup with return appointment in one week to see dr. y in orthopedics. additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.

preoperative diagnosis: , right pectoralis major tendon rupture.,postoperative diagnosis: , right pectoralis major tendon rupture.,operation performed: , open repair of right pectoralis major tendon.,anesthesia:, general with an interscalene block.,complications:, none.,needle and sponge counts were done and correct.,indication for operation: ,the patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder. the patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture. over concerns for pectoralis tendon tear, he was sent for mri evaluation where a complete rupture of a portion of the pectoralis major tendon was noted. due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result. the risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks. understanding all risks and benefits, the patient desires to proceed with surgery as planned.,findings:,1. following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered. the clavicular head was noted to be intact. there was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2. following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3. a soft tissue repair was performed with #5 fiberwire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site. following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,operative report in detail: , the patient was identified in the preop holding area. his right shoulder was identified, marked his appropriate surgical site after verification with the patient. he was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team. he then received prophylactic antibiotics. a time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment. at this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes. the right upper extremity was then prepped and draped in the usual sterile fashion. preoperative markings were still visible at this point. a deltopectoral incision was made utilizing the inferior portion. dissection was carried down. the deltoid was retracted laterally. the clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion. there was a small cuff of tissue left on the proximal humerus associated with the clavicular head. gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 ethibond were used in this to allow for retraction and freeing from light adhesion. this allowed reapproximation of the retracted tendon to the tendon stump. at this point, a repair using #5 fiberwire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site. at this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone. for this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded. the sutures were then weaved through the lateral aspect of the torn tendon and a modified krackow type performed and sutured thereby relieving tension off the soft tissue repair. at this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation. aggressive external rotation was not performed. the wound was then copiously irrigated. the cephalic vein was not injured during the case. the skin was then closed using a 2-0 vicryl followed by a 3-0 subcuticular prolene suture with steri-strips. sterile dressing was then placed. anesthesia was then performed, interscalene block. the patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days. we will then start a gentle codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.

general: ,xxx,vital signs: , blood pressure xxx, pulse xxx, temperature xxx, respirations xxx. height xxx, weight xxx.,head: , normocephalic. negative lesions, negative masses.,eyes: , perla, eomi. sclerae clear. negative icterus, negative conjunctivitis.,ent:, negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates. negative ear obstructions, negative exudates. negative inflammation in external auditory canals. negative throat inflammation or masses.,skin: , negative rashes, negative masses, negative ulcers. no tattoos.,neck:, negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,heart:, regular rate and rhythm. negative rubs, negative gallops, negative murmurs.,lungs:, clear to auscultation. negative rales, negative rhonchi, negative wheezing.,abdomen: , soft, nontender, adequate bowel sounds. negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,extremities: , negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing. pulses adequate bilaterally.,musculoskeletal:, negative muscle atrophy, negative masses. strength adequate bilaterally. negative movement restriction, negative joint crepitus, negative deformity.,neurologic: , cranial nerves i through xii intact. negative gait disturbance. balance and coordination intact. negative romberg, negative babinski. dtrs equal bilaterally.,genitourinary: ,deferred.,

delivery note: , the patient is a very pleasant 22-year-old primigravida with prenatal care with both dr. x and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital. the patient was admitted to labor and delivery on tuesday, december 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital. her cervix on admission was not ripe, so she was given a dose of cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. at a later time, pitocin was started. the next day at about 9 o'clock in the morning, i checked her cervix and performed artifical rupture of membranes, which did reveal meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then mdl infusion started. the patient did have labor epidural, which worked well. it should be noted that the patient's recent vaginal culture for group b strep did come back negative for group b strep. the patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth. the intensive care nursery staff was present because of the presence of meconium-stained amniotic fluid. delee suctioning was performed at the perineum. a second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 vicryl. the placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,estimated blood loss: , approximately 300 ml.

admitting diagnosis: , cerebrovascular accident (cva).,history of present illness: , the patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness. this occurred at 2:30 a.m. his wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room. he arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning. upon initial evaluation, he did have some left-sided weakness and was complaining of a headache. he underwent workup including a ct, which was negative and his symptoms slowly began to resolve. he was initially admitted, placed on plavix and aspirin. however a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech. repeat ct scan again done reportedly was negative and he was subsequently heparinized and admitted. he also underwent an echo, carotid ultrasound, and lab work in the emergency room. wife is at the bedside and denies he had any other symptoms previous to this. he denied any chest pain or palpitations. she does report that he is on a z-pak, got a cortisone shot, and some decongestant from dr. abc on saturday because of congestion and that had gotten better.,allergies: ,he has no known drug allergies.,current medications:,1. multivitamin.,2. ibuprofen p.r.n.,past medical history:,1. nasopharyngeal cancer. occurred in 1991. status post xrt of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2. lumbar disk disease.,3. status post diskectomy.,4. chronic neck pain secondary to xrt.,5. history of thalassemia.,6. chronic dizziness since his xrt in 1991.,past surgical history: , lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,social history: , he is a nonsmoker. he occasionally has a beer. he is married. he works as a flooring installer.,family history: ,pertinent for father who died of an inoperable brain tumour. mother is obese, but otherwise negative history.,review of systems: ,he reports he was in his usual state of health up until he awoke this morning. he does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right. he is a right-handed male and normally wears glasses.,physical examination:,vital signs: stable. his blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,general: he is alert, pleasant, and in no acute distress at this time. he answers questions appropriately.,heent: pupils are equal, round, and reactive to light. extraocular muscles are intact. sclerae are clear. tms clear. oropharynx is clear.,neck: supple with full range of motion. he does have some increased density to neck, i assume, secondary to xrt.,cardiovascular: regular rate and rhythm without murmur.,lungs: clear bilaterally.,abdomen: soft, nontender, and nondistended.,extremities: show no clubbing, cyanosis or edema.,neurologic: he does have a minimally slurred speech at present. he does have a slight facial droop. he has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left. handgrip is about 4/5 on the left, right side is 5/5.,laboratory data: ,his initial blood work, pt was 11 and ptt 27. cbc is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1. chem panel is all normal.,ekg showed normal sinus rhythm, normal ekg. ct of his brain, initially his first ct, which was done this morning at approximately 7 a.m. showed a normal ct. repeat ct done at approximately 3:30 p.m. this evening was reportedly also normal. he underwent an echocardiogram in the emergency room, which was essentially normal. he had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,mpression and plan:,1. cerebrovascular accident, in progress.

preoperative diagnoses:,1. hypermenorrhea.,2. uterine fibroids.,3. pelvic pain.,4. left adnexal mass.,5. pelvic adhesions.,postoperative diagnoses:,1. hypermenorrhea.,2. uterine fibroids.,3. pelvic pain.,4. left adnexal mass.,5. pelvic adhesions.,procedure performed:,1. total abdominal hysterectomy (tah).,2. left salpingo-oophorectomy.,anesthesia:, general endotracheal.,complications:, none.,estimated blood loss: , less than 100 cc.,indications: , the patient is a 47-year-old caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in july of 2003. the patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,findings at the time of surgery: , uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,on laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass. the bowel, omentum, and appendix had a normal appearance.,procedure: , the patient was taken to the operative suite where anesthesia was found to be adequate. she was then prepared and draped in normal sterile fashion. a pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel. the fascia was then incised in the midline. the fascial incision was then extended laterally with mayo scissors. the superior aspect of the fascial incision was grasped with kochers with the underlying rectus muscle dissected off bluntly and sharply with mayo scissors. attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with mayo scissors. the rectus muscle was then separated in the midline. the peritoneum was identified, tented up with hemostats and entered sharply with metzenbaum scissors. the peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder. the uterus and left adnexa were then palpated and brought out into the surgical field. the fundus of the uterus was grasped with a lahey clamp. the gyn/balfour retractor was placed. the bladder blade was placed. the bowel was packed away with moist laparotomy sponges and the extension through gyn/balfour retractor was placed. at this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass. attention was first turned to the right round ligament, which was tented up with a babcock and a small window was made beneath the round ligament with a hemostat. it was then suture ligated with #0 vicryl suture, transected with the broad ligament being skeletonized on both sides. next, the right ________ was isolated bluntly as the patient had a previous rso. this was then suture ligated with #0 vicryl suture, doubly clamped with kocher clamps, transected, and suture ligated with #0 vicryl suture with a heaney stitch. attention was then turned to the left round ligament, which was tented up with the babcock. small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 vicryl suture, transected, and skeletonized with the aid of metzenbaums. the left infundibulopelvic ligament was then bluntly isolated. it was then suture ligated with #0 vicryl suture, doubly clamped with kocher clamps, and transected and suture ligated with #0 vicryl suture with a heaney stitch. the bladder flap was then placed on tension with allis clamps. it was then dissected off of the lower uterine segment with the aid of metzenbaum scissors and russians. it was then gently pushed off of lower uterine segment with the aid of a moist ray-tec. the uterine arteries were then skeletonized bilaterally.,they were then clamped with straight kocher clamps, transected, and suture ligated with #0 vicryl suture. the cardinal ligament and uterosacral complexes on both sides were then clamped with curved kocher clamps. these were then transected and suture ligated with #0 vicryl suture. the lower uterine segment was then grasped with lahey clamps, at which time the cervix was already visible. it was then entered with the last transection. the cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of jorgenson scissors. the angles of the vaginal cuff were then grasped with kocher clamps. a betadine-soaked ray-tec was then pushed into the vagina and the vaginal cuff was closed with #0 vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed. good hemostasis was appreciated. a figure-of-eight suture in the center of the vaginal cuff was placed with #0 vicryl. this was tagged for later use. the uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 vicryl suture. the round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place. the pelvis was then again copiously suctioned irrigated and hemostasis was appreciated. the peritoneal surfaces were then reapproximated with the aid of #3-0 vicryl suture in a running fashion. the gyn/balfour retractor and bladder blade were then removed. the bowel was then packed. again copious suction irrigation was performed with hemostasis appreciated. the peritoneum was then reapproximated with #2-0 vicryl suture in a running fashion. the fascia was then reapproximated with #0 vicryl suture in a running fashion. the scarpa's fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed vicryl in a subcuticular fashion. steri-strips were placed. at the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally. the patient tolerated the procedure well and was taken to recovery in stable condition. sponge, lap, and needle counts were correct x2. specimens include uterus, cervix, left fallopian tube, and ovary.

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

exam: , ct cervical spine.,reason for exam: , mva, feeling sleepy, headache, shoulder and rib pain.,technique:, axial images through the cervical spine with coronal and sagittal reconstructions.,findings:, there is reversal of the normal cervical curvature at the vertebral body heights. the intervertebral disk spaces are otherwise maintained. there is no prevertebral soft tissue swelling. the facets are aligned. the tip of the clivus and occiput appear intact. on the coronal reconstructed sequence, there is satisfactory alignment of c1 on c2, no evidence of a base of dens fracture.,the included portions of the first and second ribs are intact. there is no evidence of a posterior element fracture. included portions of the mastoid air cells appear clear. there is no ct evidence of a moderate or high-grade stenosis.,impression: , no acute process, cervical spine.

preprocedure diagnosis: , colon cancer screening.,postprocedure diagnosis: ,colon polyps, diverticulosis, hemorrhoids.,procedure performed: , colonoscopy, conscious sedation, and snare polypectomy. ,indications: ,the patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy. he has had previous colonoscopy. there is no family history of bleeding, no current problems with his bowels. on examination, he has internal hemorrhoids. his prostate is enlarged and increased somewhat in firmness. he has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm. these were removed with snare polypectomy technique. i would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,procedure: , after explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg versed intravenously for conscious sedation. blood pressure 115/60, pulse 98, respiration 18, and saturation 92%. a rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve. the scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port. the scope was withdrawn into the left transverse colon, where the second polyp was identified. it was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well. the scope was then gradually withdrawn the remaining distance and removed. the patient tolerated the procedure well.

preoperative diagnosis: , cleft soft palate.,postoperative diagnosis: , cleft soft palate.,procedures:,1. repair of cleft soft palate, cpt 42200.,2. excise accessory ear tag, right ear.,anesthesia: , general.,description of procedure: , the patient was placed supine on the operating room table. after anesthesia was administered, time out was taken to ensure correct patient, procedure, and site. the face was prepped and draped in a sterile fashion. the right ear tag was examined first. this was a small piece of skin and cartilaginous material protruding just from the tragus. the lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision. dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus. after this was done, the wound was cauterized and then closed using interrupted 5-0 monocryl. attention was then turned towards the palate. the dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine. after giving this 5 minutes to take effect, the palate was incised along its margins. the anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle. muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline. the z-plasties were then designed, so there would be opposing z-plasties from the nasal mucosa compared to the oral mucosa. the nasal mucosa was sutured first using interrupted 4-0 vicryl. next, the muscle was reapproximated using interrupted 4-0 vicryl with an attempt to overlap the muscle in the midline. in addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate. following this, the oral layer of mucosa was repaired using an opposing z-plasty compared to the nasal layer. this was also sutured in place using interrupted 4-0 vicryl. the anterior and posterior open edges of the palatal were sewn together. the patient tolerated the procedure well. suction of blood and mucus performed at the end of the case. the patient tolerated the procedure well.,immediate complications: , none.,disposition:, in satisfactory condition to recovery.