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chief complaint and identification:, a is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.,history of present illness: , the patient is to known to have reactive airway disease and uses pulmicort daily and albuterol up to 4 times a day via nebulization.,she has no hospitalizations.,the patient has had a 1 week or so history of cough. she was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom. she has been taking 1 teaspoon every 6 hours. she originally was having some low-grade fever with a maximum of 100.4 degrees fahrenheit; however, on the day prior to admission, she had a 104.4 degrees fahrenheit temperature, and was having posttussive emesis. she is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to children's hospital central california.,at children's hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the hospitalist service was contacted regarding admission. the patient was seen and admitted through the emergency room.,review of systems: , negative except that indicated in the history of present illness. all systems were checked.,past medical history: , as stated in the history of present illness, no hospitalizations, no surgeries.,immunizations: , the patient is up-to-date on her shots. she has a schedule for her 2-year-old shot soon.,allergies: , no known drug allergies.,development history: , developmentally, she is within normal limits.,family history:, her maternal uncles have asthma. there are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.,social history: , her sister has a runny nose, but no other sick contacts. the family lives in delano. she lives with her mom and sister. the dad is involved, but the parents are separated. there is no smoking exposure.,physical examination:, ,general: the child was in no acute distress.,vital signs: temperature 99.8 degrees fahrenheit, heart rate 144, respiratory rate 28. oxygen saturations 98% on continuous. off of oxygen shows 85% laying down on room air. the t-max in the er was 101.3 degrees fahrenheit.,skin: clear.,heent: pupils were equal, round, react to light. no conjunctival injection or discharge. tympanic membranes were clear. no nasal discharge. oropharynx moist and clear.,neck: supple without lymphadenopathy, thyromegaly, or masses.,chest: clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.,cardiovascular: regular rate and rhythm. no murmurs noted. well perfused peripherally.,abdomen: bowel sounds are present. the abdomen is soft. there is no hepatosplenomegaly, no masses, nontender to palpation.,genitourinary: no inguinal lymphadenopathy. tanner stage i female.,extremities: symmetric in length. no joint effusions. she moves all extremities well.,back: straight. no spinous defects.,neurologic: the patient has a normal neurologic exam. she is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive. she has no focal neurologic deficits.,laboratory data: , chest x-ray by my reading shows a right lower lobe infiltrate. metabolic panel: sodium 139, potassium 3.5, chloride 106, total co2 22, bun and creatinine are 5 and 0.3 respectively, glucose 84, crp 4.3. white blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000. differential of the white count 34% lymphocytes, 55% neutrophils.,assessment and plan: , this is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress. i believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment. she will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage. she is being admitted for hypoxemia. i hope that this will resolve overnight, and she will be discharged in the morning. i will start her home medications of pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.,further interventions will depend on the clinical course.

reason for consultation: , left hip fracture.,history of present illness: , the patient is a pleasant 53-year-old female with a known history of sciatica, apparently presented to the emergency room due to severe pain in the left lower extremity and unable to bear weight. history was obtained from the patient. as per the history, she reported that she has been having back pain with left leg pain since past 4 weeks. she has been using a walker for ambulation due to disabling pain in her left thigh and lower back. she was seen by her primary care physician and was scheduled to go for mri yesterday. however, she was walking and her right foot got caught on some type of rug leading to place excessive weight on her left lower extremity to prevent her fall. since then, she was unable to ambulate. the patient called paramedics and was brought to the emergency room. she denied any history of fall. she reported that she stepped the wrong way causing the pain to become worse. she is complaining of severe pain in her lower extremity and back pain. denies any tingling or numbness. denies any neurological symptoms. denies any bowel or bladder incontinence.,x-rays were obtained which were remarkable for left hip fracture. orthopedic consultation was called for further evaluation and management. on further interview with the patient, it is noted that she has a history of malignant melanoma, which was diagnosed approximately 4 to 5 years ago. she underwent surgery at that time and subsequently, she was noted to have a spread to the lymphatic system and lymph nodes for which she underwent surgery in 3/2008.,past medical history: , sciatica and melanoma.,past surgical history: ,as discussed above, surgery for melanoma and hysterectomy.,allergies: , none.,social history: , denies any tobacco or alcohol use. she is divorced with 2 children. she lives with her son.,physical examination:,general: the patient is well developed, well nourished in mild distress secondary to left lower extremity and back pain.,musculoskeletal: examination of the left lower extremity, there is presence of apparent shortening and external rotation deformity. tenderness to palpation is present. leg rolling is positive for severe pain in the left proximal hip. further examination of the spine is incomplete secondary to severe leg pain. she is unable to perform a straight leg raising. ehl/edl 5/5. 2+ pulses are present distally. calf is soft and nontender. homans sign is negative. sensation to light touch is intact.,imaging:, ap view of the hip is reviewed. only 1 limited view is obtained. this is a poor quality x-ray with a lot of soft tissue shadow. this x-ray is significant for basicervical-type femoral neck fracture. lesser trochanter is intact. this is a high intertrochanteric fracture/basicervical. there is presence of lytic lesion around the femoral neck, which is not well delineated on this particular x-ray. we need to order repeat x-rays including ap pelvis, femur, and knee.,labs:, have been reviewed.,assessment: , the patient is a 53-year-old female with probable pathological fracture of the left proximal femur.,discussion and plan: , nature and course of the diagnosis has been discussed with the patient. based on her presentation without any history of obvious fall or trauma and past history of malignant melanoma, this appears to be a pathological fracture of the left proximal hip. at the present time, i would recommend obtaining a bone scan and repeat x-rays, which will include ap pelvis, femur, hip including knee. she denies any pain elsewhere. she does have a past history of back pain and sciatica, but at the present time, this appears to be a metastatic bone lesion with pathological fracture. i have discussed the case with dr. x and recommended oncology consultation.,with the above fracture and presentation, she needs a left hip hemiarthroplasty versus calcar hemiarthroplasty, cemented type. indication, risk, and benefits of left hip hemiarthroplasty has been discussed with the patient, which includes, but not limited to bleeding, infection, nerve injury, blood vessel injury, dislocation early and late, persistent pain, leg length discrepancy, myositis ossificans, intraoperative fracture, prosthetic fracture, need for conversion to total hip replacement surgery, revision surgery, dvt, pulmonary embolism, risk of anesthesia, need for blood transfusion, and cardiac arrest. she understands above and is willing to undergo further procedure. the goal and the functional outcome have been explained. further plan will be discussed with her once we obtain the bone scan and the radiographic studies. we will also await for the oncology feedback and clearance.,thank you very much for allowing me to participate in the care of this patient. i will continue to follow up.

preoperative diagnosis: , appendicitis.,postoperative diagnosis: , appendicitis.,procedure performed: , laparoscopic appendectomy.,anesthesia: , general endotracheal.,indication for operation: , the patient is a 42-year-old female who presented with right lower quadrant pain. she was evaluated and found to have a ct evidence of appendicitis. she was subsequently consented for a laparoscopic appendectomy.,description of procedure: , after informed consent was obtained, the patient was brought to the operating room, placed supine on the table. the abdomen was prepared and draped in usual sterile fashion. after the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made. a veress needle was inserted. abdomen was insufflated to 15 mmhg. a 5-mm port and camera placed. the abdomen was visually explored. there were no obvious abnormalities. a 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two. blunt dissection was used to isolate the appendix. appendix was separated from surrounding structures. a window was created between the appendix and the mesoappendix. gia stapler was tossed across it and fired. mesoappendix was then taken with 2 fires of the vascular load on the gia stapler. appendix was placed in an endobag and removed from the patient. right lower quadrant was copiously irrigated. all irrigation fluids were removed. hemostasis was verified. the 15-mm port was removed and the port site closed with 0-vicryl in the endoclose device. all other ports were irrigated, infiltrated with 0.25% marcaine and closed with 4-0 vicryl subcuticular sutures. steri-strips and sterile dressings were applied. overall, the patient tolerated this well, was awakened and returned to recovery in good condition.

reason for consultation: , icu management.,history of present illness: , the patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. the patient was transferred to the abcd hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting. the patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a ct scan. repeat ct scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen. the patient was taken emergently to the operating room last night by the general surgery service where proximal half of the jejunum was noted to be liquified with 3 perforations. this section of small bowel was resected, and a wound vac placed for damage control. plan was to return the patient to the operating room tomorrow for further exploration and possible re-anastomosis of the bowel. the patient is currently intubated, sedated, and on pressors for septic shock and in the down icu.,past medical history:, prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and gerd.,past surgical history:, included a cardiac cath with no interventions taken.,home medications:, include lantus insulin as well as oral hypoglycemics.,current meds:, include levophed, ativan, fentanyl drips, cefepime, flagyl, fluconazole, and vancomycin. nexium, synthroid, hydrocortisone, and angiomax, which is currently on hold.,review of systems:, unable to be obtained secondary to the patient's intubated and sedated status.,allergies: , none.,family history:, includes diabetes on his father side of the family. no other information is provided.,social history:, includes tobacco use as well as alcohol use.,physical examination:,general: the patient is currently intubated and sedated on levophed drip.,vital signs: temperature is 100.6, systolic is 110/60 with map of 80, and heart rate is 120, sinus rhythm.,neurologic: neurologically, he is sedated, on ativan with fentanyl drip as well. he does arouse with suctioning, but is unable to open his eyes to commands.,head and neck examination: his pupils are equal, round, reactive, and constricted. he has no scleral icterus. his mucous membranes are pink, but dry. he has an eg tube, which is currently 24-cm at the lip. he has a left-sided subclavian vein catheter, triple lumen.,neck: his neck is without masses or lymphadenopathy or jvd.,chest: chest has diminished breath sounds bilaterally.,abdomen: abdomen is soft, but distended with a wound vac in place. groins demonstrate a left-sided femoral outline.,extremities: his bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left. his toes are cool, and pulses are not palpable.,laboratory examination: , laboratory examination reveals an abg of 7.34, co2 of 30, o2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, co2 18, bun 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22. after stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively. lfts are all normal. amylase and lipase are normal. triglycerides are 73, inr is 2.2, ptt is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211. ua was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria. chest x-rays performed and show the tip of the eg tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles. tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,assessment and plan:, this is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion. he is status post small bowel resection. we plan to go back to operating room tomorrow for further debridement and possible closure. neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands. i did not suspect any sort of pathologic abnormality of his neurologic status as he has further ct scan of his brain, which was normal. currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator. we will form daily sedation holidays to assess his neurologic status and avoid over sedating with ativan.,1. cardiovascular. the patient currently is in septic shock requiring vasopressors maintained on map greater than 70. we will continue to try to wean the vasopressin after continued volume loading, also place svo2 catheter to assess his oxygen delivery and consumption given his state of shock. currently, his rhythm is of sinus tachycardia, i do not suspect afib or any other arrhythmia at this time. if he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function. once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2. pulmonology. currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, peep of 6, and fio2 of 60. we will wean his fio2 as tolerated to keep his saturation greater than 90% and wean his peep as tolerated to reduce preload compromise. we will keep the head of bed elevated and start chlorhexidine as swish and swallow for vap prevention.,3. gastrointestinal. the patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the smv. he is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum. we will maintain ng tube as he has a blind stump there, and we will preclude any further administration of any meds through this ng tube. i will keep him on gi prophylaxis as he is intubated. we will currently hold his tpn as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes. he will have a long-term tpn after this acute episode. his lfts are all normal currently. once he is postop tomorrow, we will restart the angiomax for his venous occlusion.,4. renal. the patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium. his critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail. he currently is started to make more urine since being volume resuscitated with hespan as well as bicarb drip. hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis. we will re-consult nephrology at this time.,5. endocrine. the patient has adrenal insufficiency based on lack of stem to cosyntropin. we will start hydrocortisone 50 q.6h.,6. infectious disease. currently, the patient is on broad-spectrum antibiotic prophylaxis imperially. given his bowel ischemia, we will continue these, and appreciate id service's input.,7. hematology. hematologically, the patient has a hypercoagulable syndrome, also had hit secondary to his heparin administration. we will restart the angiomax once he is back from the or tomorrow. currently, his inr is 2.2. therefore, he should be covered at the moment. appreciate the hematology's input in this matter.,please note the total critical care time spent at the bedside excluding central line placement was 1 hour.

name of procedure: , left heart catheterization with ventriculography, selective coronary arteriographies, successful stenting of the left anterior descending diagonal.,indication:, recurrent angina. history of coronary disease.,technical procedure: , standard judkins, right groin.,catheters used:, 6-french pigtail, 6-french jl4, 6-french jr4.,anticoagulation: , 2000 of heparin, 300 of plavix, was begun on integrilin.,complications: , none.,stent: , for stenting we used a 6-french left judkins guide. stent was a 275 x 13 zeta.,description of procedure: , i reviewed with the patient the pros, cons, alternatives and risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of cardiac chamber, resection of an artery, arrhythmia requiring countershock, infection, bleeding, allergy, and need for vascular surgery. all questions were answered and the patient decided to proceed.,hemodynamic data: , aortic pressure was within physiologic range. there was no significant gradient across the aortic valve.,angiographic data,1. ventriculogram: left ventricle was of normal size and shape with normal wall motion, normal ejection fraction.,2. right coronary artery: dominant. there was a lesion in the proximal portion in the 60% range, insignificant disease distally.,3. left coronary artery: the left main coronary artery showed insignificant disease. the circumflex arose, showed about 30% proximally. left anterior descending arose and the previously placed stent was perfectly patent. there was a large diagonal branch which showed 90% stenosis in its proximal portion. there was a lesion in the 30% to 40% range even more proximal.,i reviewed with the patient the options of medical therapy, intervention on the culprit versus bypass surgery. he desired that we intervene.,successful stenting of the left anterior descending, diagonal. the guide was placed in the left main. we easily crossed the lesion in the diagonal branch of the left anterior descending. we advanced, applied and post-dilated the 275 x 13 stent. final angiography showed 0% residual at the site of previous 90% stenosis. the more proximal 30% to 40% lesion was unchanged.,conclusion,1. successful stenting of the left anterior descending/diagonal. initially there was 90% in the diagonal after stenting. there was 0% residual. there was a lesion a bit more proximal in the 40% range.,2. left anterior descending stent remains patent.,3. 30% in the circumflex.,4. 60% in the right coronary.,5. ejection fraction and wall motion are normal.,plan: , we have stented the culprit lesion. the patient will receive a course of aspirin, plavix, integrilin, and statin therapy. we used 6-french angio-seal in the groin. all questions have been answered. i have discussed the possibility of restenosis, need for further procedures.

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

preoperative diagnosis: , abdominal mass.,postoperative diagnosis: , abdominal mass.,procedure:, paracentesis.,description of procedure: ,this 64-year-old female has stage ii endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation. at the present time, the patient is under radiation treatment. two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room. we proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days. the cytology of the fluid was negative and the culture was also negative. eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat cat scan of the abdomen and pelvis.,the cat scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size. therefore, i called the patient home and she came to the emergency department where the service was provided. at that time, i proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion. unfortunately, the catheter was open. i did not have a drainage system at that time. so, i withdrew directly with a syringe 700 ml of clear fluid. the system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment. she was given an appointment to see me in the office next monday, which is three days from now.

subjective:, this 1+ year, black female, new patient in dermatology, sent in for consult from abc practice for initial evaluation of a lifelong history of atopic eczema. the patient’s mom is from tanzania. the patient has been treated with elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some johnson's baby oil on her. the patient is a well-developed baby. appears stated age. overall health is good.,family, social, and allergy history: , the patient has eczema and a positive atopic family history. no psoriasis. no known drug allergies.,current medications:, none.,physical examination:, the patient has eczematous changes today on her face, trunk, and extremities.,impression:, atopic eczema.,treatment:,1. discussed condition and treatment with mom.,2. continue bathing twice a week.,3. discontinue hot soapy water.,4. discontinue elidel for now.,5. add aristocort cream 0.25%, polysporin ointment, aquaphor b.i.d. and p.r.n. itch. we will see her in one month if not better otherwise on a p.r.n. basis. send a letter to abc practice program.

principal diagnosis:, mesothelioma.,secondary diagnoses:, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,procedures,1. on august 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2. on august 20, 2007, thoracentesis.,3. on august 31, 2007, port-a-cath placement.,history and physical: , the patient is a 41-year-old vietnamese female with a nonproductive cough that started last week. she has had right-sided chest pain radiating to her back with fever starting yesterday. she has a history of pericarditis and pericardectomy in may 2006 and developed cough with right-sided chest pain, and went to an urgent care center. chest x-ray revealed right-sided pleural effusion.,past medical history,1. pericardectomy.,2. pericarditis.,2. atrial fibrillation.,4. rnca with intracranial thrombolytic treatment.,5

procedure:, delayed primary chest closure.,indications: , the patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 norwood operation. given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management. he is now taken back to the operative room for delayed primary chest closure.,preop dx: , open chest status post modified stage 1 norwood operation.,postop dx:, open chest status post modified stage 1 norwood operation.,anesthesia: , general endotracheal.,complications: , none.,findings:, no evidence of intramediastinal purulence or hematoma. he tolerated the procedure well.,details of procedure: , the patient was brought to the operating room and placed on the operating table in the supine position. following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion. the previously placed alloderm membrane was removed. mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned. both cavities were also irrigated and suctioned. the drains were flushed and repositioned. approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line. the sternum was then smeared with a vancomycin paste. the proximal aspect of the 5 mm rv-pa conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side. the sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches. the skin was closed with interrupted nylon sutures and a sterile dressing was placed. the peritoneal dialysis catheter, atrial and ventricular pacing wires were removed. the patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,i was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.

preoperative diagnosis: , foreign body in airway.,postoperative diagnosis:, plastic piece foreign body in the right main stem bronchus.,procedure: , rigid bronchoscopy with foreign body removal.,indications for procedure: , this patient is 7-month-old baby boy who presented to emergency room today with increasing stridor and shortness of breath according to mom. the patient had a chest x-ray and based on that there is concern by the radiology it could be a foreign body in the right main stem. the patient has been taken to the operating room for rigid bronchoscopy and foreign body removal.,description of procedure: ,the patient was taken to the operating room, placed supine, put under general mask anesthesia. using a 3.5 rigid bronchoscope we visualized between the cords into the trachea. there were some secretions but that looked okay. got down at the level of the carina to see a foreign body flapping in the right main stem. i then used graspers to grasp to try to pull into the scope itself. i could not do that, i thus had to pull the scope out along with the foreign body that was held on to with a grasper. it appeared to be consisting of some type of plastic piece that had broke off some different object. i took the scope and put it back down into the airway again. again, there was secretion in the trachea that we suctioned out. we looked down into the right bronchus intermedius. there was no other pathology noted, just some irritation in the right main stem area. i looked down the left main stem as well and that looked okay as well. i then withdrew the scope. trachea looked fine as well as the cords. i put the patient back on mask oxygen to wake the patient up. the patient tolerated the procedure well.

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

preoperative diagnosis: , right profound mixed sensorineural conductive hearing loss.,postoperative diagnosis:, right profound mixed sensorineural conductive hearing loss.,procedure performed:, right middle ear exploration with a goldenberg torp reconstruction.,anesthesia:, general ,estimated blood loss:, less than 5 cc.,complications:, none.,description of findings:, the patient consented to revision surgery because of the profound hearing loss in her right ear. it was unclear from her previous operative records and ct scan as to whether or not she was a reconstruction candidate. she had reports of stapes fixation as well as otosclerosis on her ct scan.,at surgery, she was found to have a mobile malleus handle, but her stapes was fixed by otosclerosis. there was no incus. there was no specific round window niche. there was a very minute crevice; however, exploration of this area did not reveal a niche to a round window membrane. the patient had a type of torp prosthesis, which had tilted off the footplate anteriorly underneath the malleus handle.,description of the procedure:, the patient was brought to the operative room and placed in supine position. the right face, ear, and neck prepped with ***** alcohol solution. the right ear was draped in the sterile field. external auditory canal was injected with 1% xylocaine with 1:50,000 epinephrine. a fisch indwelling incision was made and a tympanomeatal flap was developed in a 12 o'clock to the 7 o'clock position. meatal skin was elevated, middle ear was entered. this exposure included the oval window, round window areas. there was a good cartilage graft in place and incorporated into the posterior superior ***** of the drum. the previous prosthesis was found out of position as it had tilted out of position anteriorly, and there was no contact with the footplate. the prosthesis was removed without difficulty. the patient's stapes had an arch, but the ***** was atrophied. malleus handle was mobile. the footplate was fixed. consideration have been given to performing a stapedectomy with a tissue seal and then returning later for prosthesis insertion; however, upon inspection of the round window area, there was found to be no definable round window niche, no round window membrane. the patient was felt to have obliterated otosclerosis of this area along with the stapes fixation. she is not considered to be a reconstruction candidate under the current circumstances. no attempt was made to remove bone from the round window area. a different style of goldenberg torp was placed on the footplate underneath the cartilage support in hopes of transferring some sound conduction from the tympanic membrane to the footplate. the fit was secure and supported with gelfoam in the middle ear. the tympanomeatal flap was returned to anatomic position supported with gelfoam saturated ciprodex. the incision was closed with #4-0 vicryl and individual #5-0 nylon to the skin, and a sterile dressing was applied.

preoperative diagnosis:, completely bony impacted teeth #1, #16, #17, and #32.,postoperative diagnosis: , completely bony impacted teeth #1, #16, #17, and #32.,procedure: , surgical removal of completely bony impacted teeth #1, #16, #17, and #32.,anesthesia: , general nasotracheal.,complications: , none.,condition: ,stable to pacu.,description of procedure: , patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure. a gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 7.2 ml of lidocaine 2% with 1:100,000 epinephrine, and 3.6 ml of bupivacaine 0.5% with 1:200,000 epinephrine. beginning on the upper right tooth #1, incision was made with a #15 blade. envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator. potts elevator was then used to luxate the tooth from the socket. remnants of the follicle were then removed with hemostat. the area was irrigated and then closed with 3-0 gut suture. on the lower right tooth #32, incision was made with a #15 blade. envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with a high-speed drill with a round bur. tooth was then sectioned with the bur and removed in several pieces. remnants of the follicle were removed with a curved hemostat. the area was irrigated with normal saline solution and closed with 3-0 gut sutures. moving to #16 on the upper left, incision was made with a #15 blade. envelope flap was raised with the periosteal elevator, and bone was removed on the buccal aspect with straight elevator. potts elevator was then used to luxate the tooth from the socket. remnants of the follicle were removed with a curved hemostat. the area was irrigated with normal saline solution and closed with 3-0 gut sutures. moving to the lower left #17, incision was made with a #15 blade. envelope flap was raised with the periosteal elevator, and bone was removed on the buccal and distal aspect with high-speed drill with a round bur. then the bur was used to section the tooth vertically. tooth was removed in several pieces followed by the removal of the remnants of the follicle. the area was irrigated with normal saline solution and closed with 3-0 gut sutures. upon completion of the procedure, the throat pack was removed and the pharynx was suctioned. an ng tube was then inserted and small amount of gastric contents were suctioned. patient was then awakened, extubated, and taken to the pacu in stable condition.

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.

title of procedure: , percutaneous liver biopsy.,analgesia: , 2% lidocaine.,allergies: , the patient denied any allergy to iodine, lidocaine or codeine.,procedure in detail: ,the procedure was described in detail to the patient at a previous clinic visit and by the medical staff today. the patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death. the risks and benefits of the procedure were understood, and the patient signed the consent form freely.,with the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion. the area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver. next, a small incision was made with a bard-parker #11 scalpel. a 16-gauge modified klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration. liver cores measuring *** cm were obtained and will be sent to pathology for routine histologic study.,post-procedure course and disposition: , the patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication. normal activities can be resumed tomorrow. the patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop. an appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,complications:, none.,recommendations: , prior to discharge, hepatitis a and b vaccines will be recommended. risks and benefits for vaccination have been addressed and the patient will consider this option.

constitutional:, normal; negative for fever, weight change, fatigue, or aching.,heent:, eyes normal; negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects. ears normal; negative for hearing or balance problems. nose normal; negative for runny nose, sinus problems, or nosebleeds. mouth normal; negative for dental problems, dentures, or bleeding gums. throat normal; negative for hoarseness, difficulty swallowing, or sore throat.,cardiovascular:, normal; negative for angina, previous mi, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,pulmonary: , normal; negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,gastrointestinal: , normal; negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,genitourinary:, normal female or male; negative for incontinence, uti, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,skin: , normal; negative for rashes, keratoses, skin cancers, or acne.,musculoskeletal: , normal; negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,neurologic: , normal; negative for blackouts, headaches, seizures, stroke, or dizziness.,psychiatric: , normal; negative for anxiety, depression, or phobias.,endocrine:, normal; negative for diabetes, thyroid, or problems with cholesterol or hormones.,hematologic/lymphatic: , normal; negative for anemia, swollen glands, or blood disorders.,immunologic: , negative; negative for steroids, chemotherapy, or cancer.,vascular:, normal; negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.

chief complaint: ,leaking nephrostomy tube.,history of present illness: , this 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube. the leaking began this a.m. the patient denies any pain, does not have fever and has no other problems or complaints. the patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure. the patient states he feels like his usual self and has no other problems or concerns. the patient denies any fever or chills. no nausea or vomiting. no flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,review of systems: , review of systems otherwise negative and noncontributory.,past medical history: , metastatic prostate cancer, anemia, hypertension.,medications: , medication reconciliation sheet has been reviewed on the nurses' note.,allergies: , no known drug allergies.,social history: , the patient is a nonsmoker.,physical examination: ,vital signs: temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal. constitutional: the patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well. heent: eyes are normal with clear sclerae and cornea. neck: supple, full range of motion. cardiovascular: heart has regular rate and rhythm without murmur, rub or gallop. peripheral pulses are +2. no dependent edema. respirations: clear to auscultation bilaterally. no shortness of breath. no wheezes, rales or rhonchi. good air movement bilaterally. gastrointestinal: abdomen is soft, nontender, nondistended. no rebound or guarding. normal benign abdominal exam. musculoskeletal: the patient has nontender back and flank. no abnormalities noted to the back other than the bilateral nephrostomy tubes. the nephrostomy tube left has no abnormalities, no sign of infection. no leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it. there is no obvious active leak from the ostomy site. no sign of infection. no erythema, swelling or tenderness. the collection bag is full of clear urine. the patient has no abnormalities on his legs. skin: no rashes or lesions. no sign of infection. neurologic: motor and sensory are intact to the extremities. the patient has normal ambulation, normal speech. psychiatric: alert and oriented x4. normal mood and affect. hematologic and lymphatic: no bleeding or bruising.,emergency department course:, reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both dr. x and dr. y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes. there was no consultation dictated for this and no name was mentioned in the discharge summary, paged dr. x as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes. dr. a responded to the page and recommended __________ off a bmp and discussing it with dr. b, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged dr. x and received a call back from dr. x. dr. x stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow. this was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by dr. x was explained and understood.,diagnoses:,1. weak nephrostomy site for the right nephrostomy tube.,2. prostate cancer, metastatic.,3. ureteral obstruction.,the patient on discharge is stable and dispositioned to home.,plan: , we will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by dr. x. the patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.

general appearance: , this is a well-developed and well-nourished, ??,vital signs: , blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees fahrenheit. height is ?? feet ?? inches. weight is ?? pounds. this yields a body mass index of ??.,head, eyes, ears, nose and throat:, the pupils were equal, round and reactive to light. extraocular movements are intact. sclera are nonicteric. ears, nose, mouth and throat - externally the ears and nose are normal. the mucous membranes are moist and midline.,neck: ,the neck is supple without masses. no thyromegaly, no carotid bruits, no adenopathy.,lungs: ,there is a normal respiratory effort. bilateral breath sounds are clear. no wheezes or rales or rhonchi.,cardiac: , normal cardiac impulse location. s1 and s2 are normal. no rubs, murmurs or gallops. a regular rate and rhythm. there are no abdominal aortic bruits. the carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,extremities: , the extremities are without clubbing, cyanosis, or edema.,chest: , the chest examination is unremarkable.,breasts: ,the breasts show no masses or tenderness. no axillary adenopathy.,abdomen:, the abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,rectal: , examination was deferred.,lymphatic: , no neck, axillary or groin adenopathy was noted.,skin examination:, unremarkable.,musculoskeletal examination: , grossly normal.,neurologic: , the cranial nerves two through twelve are grossly intact. patellar and biceps reflexes are normal.,psychiatric: , the patient is awake, alert and oriented times three. judgment and insight are good. affect is appropriate.

preoperative diagnosis: , herniated nucleus pulposus, c5-c6, with spinal stenosis.,postoperative diagnosis: , herniated nucleus pulposus, c5-c6, with spinal stenosis.,procedure: , anterior cervical discectomy with fusion c5-c6.,procedure in detail: , the patient was placed in supine position. the neck was prepped and draped in the usual fashion. an incision was made from midline to the anterior border of the sternocleidomastoid in the right side. skin and subcutaneous tissue were divided sharply. trachea and esophagus were retracted medially. carotid sheath was retracted laterally. longus colli muscles were dissected away from the vertebral bodies of c5-c6. we confirmed our position by taking intraoperative x-rays. we then used the operating microscope and cleaned out the disk completely. we then sized the interspace and then tapped in a #7 mm cortical cancellous graft. we then used the depuy dynamic plate with 14-mm screws. jackson-pratt drain was placed in the prevertebral space and brought out through a separate incision. the wound was closed in layers using 2-0 vicryl for muscle and fascia. the blood loss was less than 10-20 ml. no complication. needle count, sponge count, and cottonoid count was correct.

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

history: , this child is seen for a sports physical.,nutritional history:, she takes meats, vegetables, and fruits. eats well. has may be 1 to 2 cups a day of milk. her calcium intake could be better. she does not drink that much pop but she likes koolaid. her stools are normal. brushes her teeth. sees a dentist.,developmental history: , she did well in school last year. hearing and vision, no problems. she wears corrective lenses. she will be in 8th grade and involved in volleyball, basketball, and she will be moving to texas. she did go to burton this last year. she also plays clarinet, and will be involved also in cheerleading. she likes to swim in the summer time. her menarche was january 2004. it occurs every 7 weeks. no particular problems at this time.,other activities: ,tv time about 2 to 3 hours a day. she does not use drugs, alcohol, or smoke, and denies sexual activity.,medications:, advair 250/50 b.i.d., flonase b.i.d., allegra q.d. 120 mg, xopenex and albuterol p.r.n.,allergies:, no known drug allergies.,objective:,vital signs: blood pressure: 98/60. temperature: 96.6 tympanic. weight: 107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches. her body mass index is 18.1, which is 40th percentile. pulse: 68.,heent: normocephalic. fundi benign. pupils are equal and reactive to light and accommodation. conjunctivae were non-injected. her pupils were equal, and reactive to light and accommodation. no strabismus. she wears glasses. her vision was 20/20 in both eyes. tms are bilaterally clear. nonerythematous. hearing in the ears, she was able to pass 40 decibel to 30 decibel. with the right ear, she has some problems, but the left ear she passed. throat was clear. nonerythematous. good dentition.,neck: supple. thyroid normal sized. no increased lymphadenopathy in the submandibular nodes and no axillary nodes.,respiratory: clear. no wheezes and no crackles. no tachypnea and no retractions.,cardiovascular: regular rate and rhythm. s1 and s2 normal. no murmur.,abdomen: soft. no organomegaly and no masses. no hepatosplenomegaly.,gu: normal female genitalia. tanner stage iii in breast and pubic hair development and she was given a breast exam. negative for any masses.,skin: without rash.,extremities: deep tendon reflexes 2+/4+ bilaterally and equal.,neurological: romberg negative.,back: no scoliosis.,she had good circumduction at the shoulder joints and duck walk is normal.,assessment:, sports physical with normal growth and development.,plan:, if problems continue, she will need to have her hearing rechecked. hopefully in the school, there will be a screening mat. she received her first hepatitis a vaccine and she needs to have a booster in 6 to 12 months. we reviewed her immunizations for tetanus and her last acellular dpt was 11/25/1996. when she goes to texas, mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release. we talked about her menarche. recommended the exam of the breast regularly. talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications. she also has had problems with her ankles in the past. she had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.

type of procedure: , esophagogastroduodenoscopy with biopsy.,preoperative diagnosis:, abdominal pain.,postoperative diagnosis:, normal endoscopy.,premedication: , fentanyl 125 mcg iv, versed 8 mg iv.,indications: ,this healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods. she has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time. she was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing. ultrasound was normal and a hida scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain. endoscopy was requested to make sure there is not upper gi source of her pain before considering cholecystectomy.,procedure: , the patient was premedicated and the olympus gif 160 video endoscope advanced to the distal duodenum. gastric biopsies were taken to rule out helicobacter and the procedure was completed without complication.,impression: ,normal endoscopy.,plan: , refer to a general surgeon for consideration of cholecystectomy.

preoperative diagnosis: ,right lower lobe mass, possible cancer.,postoperative diagnosis: , non-small cell carcinoma of the right lower lobe.,procedures:,1. right thoracotomy.,2. extensive lysis of adhesions.,3. right lower lobectomy.,4. mediastinal lymphadenectomy.,anesthesia: , general.,description of the procedure: , the patient was taken to the operating room and placed on the operating table in the supine position. after an adequate general anesthesia was given, she was placed in the left lateral decubitus and the right chest was prepped and draped in the sterile fashion. lateral thoracotomy was performed on the right side anterior to the tip of the scapula, and this was carried down through the subcutaneous tissue. the latissimus dorsi muscle was partially transected and then the serratus was reflected anteriorly. the chest was entered through the fifth intercostal space. a retractor was placed and then extensive number of adhesions between the lung and the pleura were lysed carefully with sharp and blunt dissection. the right lower lobe was identified. there was a large mass in the superior segment of the lobe, which was very close to the right upper lobe, and because of the adhesions, it could not be told if the tumor was extending into the right upper lobe, but it appeared that it did not. dissection was then performed at the lower lobe of the fissure, and a gia stapler was placed through here to separate the tumor from the upper lobe including a small segment of the upper lobe with the lower lobe. then, dissection of the hilum was performed, and the branches of the pulmonary artery to the lower lobe were ligated with #2-0 silk freehand ties proximally and distally and #3-0 silk transfixion stitches and then transected. the inferior pulmonary vein was dissected after dividing the ligament, and it was stapled proximally and distally with a ta30 stapler and then transected. further dissection of the fissure allowed for its completion with a gia stapler and then the bronchus was identified and dissected. the bronchus was stapled with a ta30 bronchial stapler and then transected, and the specimen was removed and sent to the pathology department for frozen section diagnosis. the frozen section diagnosis was that of non-small cell carcinoma, bronchial margins free and pleural margins free. the mediastinum was then explored. no nodes were identified around the pulmonary ligament or around the esophagus. subcarinal nodes were dissected, and hemostasis was obtained with clips. the space below and above the osseous was opened, and the station r4 nodes were dissected. hemostasis was obtained with clips and with electrocautery. all nodal tissue were sent to pathology as permanent specimen. following this, the chest was thoroughly irrigated and aspirated. careful hemostasis was obtained and a couple of air leaks were controlled with #6-0 prolene sutures. then, two #28 french chest tubes were placed in the chest, one posteriorly and one anteriorly, and secured to the skin with #2-0 nylon stitches. the incision was then closed with interrupted #2-0 vicryl pericostal stitches. a running #1 pds on the muscle layer, a running 2-0 pds in the subcutaneous tissue, and staples on the skin. a sterile dressing was applied, and the patient was then awakened and transferred to the following intensive care unit in stable and satisfactory condition.,estimated blood loss: , 100 ml.,transfusions:, none.,complications:, none.,condition: , condition of the patient on arrival to the intensive care unit was satisfactory.

indication for study: , chest pains, cad, and cardiomyopathy.,medications:, humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,baseline ekg: , sinus rhythm at 71 beats per minute, left anterior fascicular block, lvbb.,persantine results: , heart rate increased from 70 to 72. blood pressure decreased from 160/84 to 130/78. the patient felt slightly dizziness, but there was no chest pain or ekg changes.,nuclear protocol: , same day rest/stress protocol was utilized with 12 mci for the rest dose and 33 mci for the stress test. 53 mg of persantine were used, reversed with 125 mg of aminophylline.,nuclear results:,1. nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. the resting images are normal. the post persantine images show mildly decreased uptake in the septum. the sum score is 0.,2. the gated spect shows enlarged heart with a preserved ef of 52%.,impression:,1. mild septal ischemia. likely due to the left bundle-branch block.,2. mild cardiomyopathy, ef of 52%.,3. mild hypertension at 160/84.,4. left bundle-branch block.,

chief complaint: , "i want my colostomy reversed.",history of present illness: , mr. a is a pleasant 43-year-old african-american male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia. the patient states that in november 2007, he presented to high point regional hospital with sharp left lower quadrant pain and was emergently taken to surgery where he woke up with a "bag." according to some notes that were faxed to our office from the surgeon in high point who performed his initial surgery, dr. x, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and hartmann's pouch. the patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic. the patient also complains of the development of an incisional hernia since his surgery in november. he was seen back by dr. x in april 2008 and hopes that dr. x may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by dr. x. currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort. he feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,past medical and surgical history:,1. gastroesophageal reflux disease.,2. question of hypertension.,3. status post sigmoid colectomy with end colostomy and hartmann's pouch in november 2007 at high point regional.,4. status post cholecystectomy.,7. status post unknown foot surgery.,medications:, none.,allergies: , no known drug allergies.,social history: , the patient lives in greensboro. he smokes one pack of cigarettes a day and has done so for 15 years. he denies any iv drug use and has an occasional alcohol.,family history: ,positive for diabetes, hypertension, and coronary artery disease.,review of systems: , please see history of present illness; otherwise, the review of systems is negative.,physical examination:,vital signs: temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,general: this is a pleasant african-american male appearing his stated age in no acute distress.,heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light and accommodation. moist mucous membranes. extraocular movements intact.,neck: supple, no jvd, and no lymphadenopathy.,cardiovascular: regular rate and rhythm.,lungs: clear to auscultation bilaterally.,abdomen: soft, nontender, and nondistended with a left lower quadrant stoma. the stoma is pink, protuberant, and productive. the patient also has a midline incisional hernia approximately 6 cm in diameter. it is reducible. otherwise, there are no further hernias or masses noted.,extremities: no clubbing, cyanosis or edema.,assessment and plan: ,this is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and hartmann's pouch in november of 2007 secondary to perforated colon from diverticulitis. the patient presents for reversal of his colostomy as well as repair of his incisional hernia. i have asked the patient to return to high point regional and get his medical records including the operative note and pathology results from his initial surgery so that i would have a better idea of what was done during his initial surgery. he stated that he would try and do this and bring the records to our clinic on his next appointment. i have also set him up for a barium enema to study the rectal stump. he will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point. this was discussed with the patient as well as his sister and significant other in the clinic today. they were in agreement with this plan. we also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag. to my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,

reason for referral:, chest pain, possible syncopal spells.,she is a very pleasant 31-year-old mother of two children with add.,she was doing okay until january of 2009 when she had a partial hysterectomy. since then she just says "things have changed". she just does not want to go out anymore and just does not feel the same. also, at the same time, she is having a lot of household stressors with both of her children having add and odd and she feels she does not get enough support from her husband. her 11-year-old is having a lot of trouble at school and she often has to go there to take care of problems.,in this setting, she has been having multiple cardiovascular complaints including chest pains, which feel "like cramps" and sometimes like a dull ache, which will last all day long. she is also tender in the left breast area and gets numbness in her left hand. she has also had three spells of "falling", she is not really clear on whether these are syncopal, but they sound like they could be as she sees spots before her eyes. twice it happened, when getting up quickly at night and another time in the grocery store. she suffered no trauma. she has no remote history of syncope. her weight has not changed in the past year.,medications: , naprosyn, which she takes up to six a day.,allergies:, sulfa.,social history: , she does not smoke or drink. she is married with two children.,review of systems:, otherwise unremarkable.,pex:, bp: 130/70 without orthostatic changes. pr: 72. wt: 206 pounds. she is a healthy young woman. no jvd. no carotid bruit. no thyromegaly. cardiac: regular rate and rhythm. there is no significant murmur, gallop, or rub. chest: mildly tender in the upper pectoral areas bilaterally (breast exam was not performed). lungs: clear. abdomen: soft. moderately overweight. extremities: no edema and good distal pulses.,ekg: , normal sinus rhythm, normal ekg.,echocardiogram (for syncope): , essentially normal study.,impression:,1. syncopal spells - these do sound, in fact, to be syncopal. i suspect it is simple orthostasis/vasovagal, as her ekg and echocardiogram looks good. i have asked her to drink plenty of fluids and to not to get up suddenly at night. i think this should take care of the problem. i would not recommend further workup unless these spells continue, at which time i would recommend a tilt-table study.,2. chest pains - atypical for cardiac etiology, undoubtedly due to musculoskeletal factors from her emotional stressors. the naprosyn is not helping that much, i gave her a prescription for flexeril and instructed her in its use (not to drive after taking it).,recommendations:,1. reassurance that her cardiac checkup looks excellent, which it does.,2. drink plenty of fluids and arise slowly from bed.,3. flexeril 10 mg q 6 p.r.n.,4. i have asked her to return should the syncopal spells continue.

preoperative diagnosis: , recurrent vulvar melanoma.,postoperative diagnosis: , recurrent vulvar melanoma.,operation performed: , radical anterior hemivulvectomy. posterior skinning vulvectomy.,specimens: , radical anterior hemivulvectomy, posterior skinning vulvectomy.,indications for procedure: , the patient has a history of vulvar melanoma first diagnosed in november of 1995. she had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris. biopsy obtained by the patient confirmed recurrence. in addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,findings: , during the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris. no other obvious lesions were seen. the room was darkened and a woods lamp was used to inspect the epithelium. a marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,procedure: , the patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen. the radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm. subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum. after removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized. skin was incised with a scalpel and electrocautery was used to undermine. after removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 vicryl suture. the final sponge, needle, and instrument counts were correct at the completion of the procedure. the patient was then taken to the post anesthesia care unit in stable condition.

problem list:,1. refractory hypertension, much improved.,2. history of cardiac arrhythmia and history of pacemaker secondary to av block.,3. history of gi bleed in 1995.,4. history of depression.,history of present illness:, this is a return visit to the renal clinic for this patient. she is an 85-year-old woman with history as noted above. her last visit was approximately four months ago. since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously. she is not reporting any untoward side effect. she is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing. she has no orthopnea. her exercise capacity is about the same. the only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine. no history of extremity pain.,current medications:,1. triamterene/hydrochlorothiazide 37.5/25 mg.,2. norvasc 10 mg daily.,3. atenolol 50 mg a day.,4. atacand 32 mg a day.,5. cardura 4 mg a day.,physical examination:,vital signs: temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56. thorax: revealed lungs that are clear, pa and lateral without adventitious sounds. cardiovascular: demonstrated regular rate and rhythm. s1 and s2 without murmur. no s3. i could not hear murmur today. abdomen: above plane, but nontender. extremities: revealed no edema.,assessment:, this is a return visit for this patient who has refractory hypertension. this seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. we had discussed with her in the past beginning to see an internist at the senior center. she apparently had an appointment scheduled and it was missed. we are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of gfr that is greater than 60%.,plan: , the plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us. in the meantime, we will discharge her from our practice. should there be confusion or difficulty getting in the senior center, we can always see her back in followup

subjective:, the patient's assistant brings in her food diary sheets. the patient says she stays active by walking at the mall.,objective:, weight today is 201 pounds, which is down 3 pounds in the past month. she has lost a total of 24 pounds. i praised this and encouraged her to continue. i went over her food diary. i praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free kool-aid, sugar-free jell-o, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern. i encouraged her to continue all of this.,assessment:, the patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity. she needs to continue all this.,plan:, followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.

exam: , mri of lumbar spine without contrast.,history:, a 24-year-old female with chronic back pain.,technique: , noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,findings: , the visualized cord is normal in signal intensity and morphology with conus terminating in proper position. visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process. there are no paraspinal masses.,disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,l5-s1: central canal, neural foramina are patent.,l4-l5: central canal, neural foramina are patent.,l3-l4: central canal, neural foramen is patent.,l2-l3: central canal, neural foramina are patent.,l1-l2: central canal, neural foramina are patent.,the visualized abdominal aorta is normal in caliber. incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,impression: , no acute disease in the lumbar spine.

description of operation:, the patient was brought to the operating room and appropriately identified. local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block. the patient was prepped and draped in the usual sterile fashion. a lid speculum was used to provide exposure to the right eye.,a limited conjunctival peritomy was created with westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants. calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,a 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark. the mvr blade was used to make a sclerotomy between the pre-placed sutures. an 8-0 nylon suture was then pre-placed for later sclerotomy closure. the infusion cannula was inspected and found to be in good working order. the infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures. the tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants. the light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed. there was moderately severe vitreous hemorrhage, which was removed. once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades. these were dissected with curved scissors and judicious use of the vitrectomy cutter. there was some bleeding from the inferotemporal frond. this was managed by raising the intraocular pressure and using intraocular cautery. the surgical view became cloudy and the corneal epithelium was removed with a beaver blade. this improved the view. there is an area suspicious for retinal break near where the severe traction was inferotemporally. the endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment. the indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen. there was some residual hemorrhagic vitreous skirt seen. the soft-tip cannula was then used to perform an air-fluid exchange. additional laser was placed around the suspicious area inferotemporally. the sclerotomies were then closed with 8-0 nylon suture in an x-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,the conjunctiva was closed with 6-0 plain gut. a subconjunctival injection of ancef and decadron were given and a drop of atropine was instilled over the eye. the lid speculum was removed. maxitrol ointment was instilled over the eye and the eye was patched. the patient was brought to the recovery room in stable condition.

hdr brachytherapy,the intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified. simulation films were obtained, documenting its positioning. the 3-dimensional treatment planning process was accomplished utilizing the ct derived data. a treatment plan was selected utilizing sequential dwell positions within a single catheter. the patient was taken to the treatment area. the patient was appropriately positioned and the position of the intracavitary device was checked. catheter length measurements were taken. appropriate measurements of the probe dimensions and assembly were also performed. the applicator was attached to the hdr after-loader device. the device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication. the brachytherapy source was appropriately removed back to the brachytherapy safe within the device. radiation screening was performed with the geiger-muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,following completion of the procedure, the intracavitary device was removed without difficulty. the patient was in no apparent distress and was discharged home.

preoperative diagnoses:,1. chronic otitis media with effusion.,2. conductive hearing loss.,postoperative diagnoses:,1. chronic otitis media with effusion.,2. conductive hearing loss.,procedure performed: , bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,anesthesia: ,total iv general mask airway.,estimated blood loss: ,none.,complications: , none.,indications for procedure:, the patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy. after risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,procedure:, the patient was brought to the operative suite by anesthesia. the patient was placed on the operating table in supine position. after this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,the zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction. after this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma. a myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents. a _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep. cortisporin otic drops were placed followed by cotton balls. attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed. the external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane. the tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels. a myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep. after this, the patient had cortisporin otic drops followed by cotton balls placed. the patient was then turned back to anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well. the patient will be followed up approximately in one week and was sent home with a prescription for ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.

operative diagnoses: , chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,operations performed: , septoplasty with partial inferior middle turbinectomy with ktp laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,operation: , the patient was taken to the operating room. after adequate anesthesia via endotracheal intubation, the nose was prepped with afrin nasal spray. after this was done, 1% xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium. after this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate. a 45-degree forceps then used to open up the maxillary sinus. there was some prominent tissue and just superior to this, the anterior ethmoid was opened. the 45-degree forceps was then used to open the maxillary sinus ostium. this was enlarged with backbiting rongeur. after this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa. after this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate. there was noted to have prominence in the anterior ethmoidal area. this was then opened with 45-degree forceps. this mucosa was then removed from the anterior area. the maxillary sinus ostium was then opened with 45-degree forceps. tissue was removed from this area. this was sent as right maxillary mucosa. after this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus. protecting the eyes with wet gauze and using ktp laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally. this was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction. after this was completed, a septoplasty was performed. the incision was made with a #15 blade bard-parker knife. the flap was then elevated, overlying the spur that was protruding into the right nasal cavity. this was excised with a #15 blade bard-parker knife. the tissue was then laid back in position. after this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx. , ,surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon. the patient was then awakened and taken to recovery room in good condition.

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

reason for consultation: , renal failure.,history of present illness:, thank you for referring ms. abc to abcd nephrology. as you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to xyz hospital. she had been admitted at that time with chest pain and was subsequently transferred to university of a and had a cardiac catheterization, which did not show any coronary artery disease. she also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin. her creatinine both at xyz hospital and university of a was elevated at 2.4. i do not have the results from the prior years. a repeat creatinine on 08/16/06 was 2.3. the patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration. she also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection. she had bladder studies a long time ago. she complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria. she also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones. she denies any nonsteroidal antiinflammatory drug use. she denies any other over-the-counter medication use. she has chronic hypokalemia and has been on potassium supplements recently. she is unsure of the dose. ,past medical history: ,1. hypertension on and off for years. she states she has been treated intermittently but lately has again been off medications.,2. gastroesophageal reflux disease.,3. gastritis.,4. hiatal hernia.,5. h. pylori infection x3 in the last six months treated.,6. chronic hypokalemia secondary to chronic diarrhea.,7. recurrent admissions with nausea, vomiting, and dehydration. ,8. renal cysts found on a cat scan of the abdomen.,9. no coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease. ,10. stomach bypass surgery 1975 with chronic diarrhea.,11. history of uti multiple times recently.,12. questionable history of kidney stones.,13. history of gingival infection secondary to chronic steroid use, which was discontinued in july 2001.,14. depression.,15. diffuse degenerative disc disease of the spine.,16. hypothyroidism.,17. history of iron deficiency anemia in the past. ,18. hyperuricemia. ,19. history of small bowel resection with ulcerative fibroid. ,20. occult severe gi bleed in july 2001.,past surgical history: , the patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck april 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor august 4, 2005. ,current medications: ,1. nexium 40 mg q.d.,2. synthroid 1 mg q.d. ,3. potassium one q.d., unsure about the dose. ,4. no history of nonsteroidal drug use.,allergies:

history: , this 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. in summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,recommendations: , i do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues. i went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through memorial medical center.

reason for exam: , lower quadrant pain with nausea, vomiting, and diarrhea.,technique: , noncontrast axial ct images of the abdomen and pelvis are obtained.,findings: , please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,gallstones are seen within the gallbladder lumen. no abnormal pericholecystic fluid is seen.,the liver is normal in size and attenuation.,the spleen is normal in size and attenuation.,a 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas. no pancreatic ductal dilatation is seen. there is no abnormal adjacent stranding. no suspected pancreatitis is seen.,the kidneys show no stone formation or hydronephrosis.,the large and small bowels are normal in course and caliber. there is no evidence for obstruction. the appendix appears within normal limits.,in the pelvis, the urinary bladder is unremarkable. there is a 4.2 cm cystic lesion of the right adnexal region. no free fluid, free air, or lymphadenopathy is detected.,there is left basilar atelectasis.,impression:,1. a 2.2 cm low attenuation lesion is seen at the pancreatic tail. this is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised. additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed. alternatively, an mri may be obtained.,2. cholelithiasis.,3. left basilar atelectasis.,4. a 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.

preoperative diagnoses: , vault prolapse and rectocele.,postoperative diagnoses:, vault prolapse and rectocele.,operation: , colpocleisis and rectocele repair.,anesthesia: ,spinal.,estimated blood loss:, minimal.,fluids: , crystalloid.,brief history of the patient: , this is an 85-year-old female who presented to us with a vaginal mass. on physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy. the patient had good anterior support at the bladder. options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed. risk of anesthesia, bleeding, infection, pain, mi, dvt, pe, morbidity, and mortality of the procedure were discussed., ,risk of infection and abscess formation were discussed. the patient understood all the risks and benefits and wanted to proceed with the procedure. risk of retention and incontinence were discussed. consent was obtained through the family members.,details of the or:, the patient was brought to the or. anesthesia was applied. the patient was placed in dorsal lithotomy position. the patient had a foley catheter placed. the posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support. a 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part. attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring. discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive. family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis. oral consent was obtained from the family and her surgery was preceded. the vaginal mucosa was denuded off using electrocautery and metzenbaum scissors. using 0 vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus. the vaginal mucosa was pretty much completely closed off all the way up to the introitus. indigo carmine was given. cystoscopy revealed there was a good efflux of urine from both of the ureteral openings. there was no injury to the bladder or kinking of the ureteral openings. the bladder was normal. rectal exam was normal at the end of the colpocleisis repair. there was good hemostasis., ,at the end of the procedure, foley was removed and the patient was brought to recovery in a stable condition.

subjective:, overall, she has been doing well. her blood sugars have usually been less than or equal to 135 by home glucose monitoring. her fasting blood sugar today is 120 by our accu-chek. she is exercising three times per week. review of systems is otherwise unremarkable. ,objective:, her blood pressure is 110/60. other vitals are stable. heent: unremarkable. neck: unremarkable. lungs: clear. heart: regular. abdomen: unchanged. extremities: unchanged. neurologic: unchanged. ,assessment:, ,1. niddm with improved control. ,2. hypertension. ,3. coronary artery disease status post coronary artery bypass graft. ,4. degenerative arthritis. ,5. hyperlipidemia. ,6. hyperuricemia. ,7. renal azotemia. ,8. anemia. ,9. fibroglandular breasts. ,plan:, we will get follow-up labs today. we will continue with current medications and treatment. we will arrange for a follow-up mammogram as recommended by the radiologist in six months, which will be approximately month dd, yyyy. the patient is advised to proceed with previous recommendations. she is to follow-up with ophthalmology and podiatry for diabetic evaluation and to return for follow-up as directed.

diagnosis: ,shortness of breath. fatigue and weakness. hypertension. hyperlipidemia.,indication: , to evaluate for coronary artery disease.,

cc:, dysarthria,hx: ,this 52y/o rhf was transferred from a local hospital to uihc on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. she was a belted passenger in a car struck at a stop. there was no reported head or neck injury or alteration of consciousness. she was treated and released from a local er the same day. her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. in 4/94 she developed stress urinary incontinence which spontaneously resolved in june. in 8/94, her ha changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. she also began experiencing increased blurred vision, worsening dysarthria and difficulty hand writing. in 9/94 she was evaluated by a local physician. examination then revealed incoordination, generalized fatigue, and dysarthria. soon after this she became poorly arousable and increasingly somnolent. she had difficulty walking and generalized weakness. on 10/14/94, she lost the ability to walk by herself. evaluation at a local hospital revealed: 1)normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of "tumor or reactive lymphocytosis." one of these csf analysis showed: glucose 16, protein 99, wbc 14, rbc 114. echocardiogram was normal. bone marrow biopsy was normal except for decreased iron. abdominal-pelvic ct scan, cxr, mammogram, ppd, ana, tft, and rpr were unremarkable. a 10/31/94 mri brain scan a 5x10mm area of increased signal on t2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. these areas did not enhance with gadolinium contrast on t1 weighted images.,meds: ,none.,pmh:, 1)g3p3, 2)last menses one year ago.,fhx:, mother suffered stroke in her 70's. dm and htn in family.,shx:, married, secretary, no h/o tobacco/etoh/illicit drug use.,ros:, no weight loss, fever, chills, nightsweats, cough, dysphagia.,exam:, bp139/74, hr 90, rr20, 36.8c,ms: drowsy to somnolent, occasionally "giddy." oriented to person, place, time. minimal dysarthric speech, but appropriate. mmse 27/30 (copy of exam not in chart).,cn: pupils 4/4 decreasing to 2/2 on exposure to light. optic disks were flat and without sign of papilledema. vfftc. eom intact. no nystagmus. the rest of the cn exam was unremarkable.,motor: 5/5 strength throughout. normal muscle tone and bulk.,sensory: no deficit to lt/pp/vib/prop.,coord: difficulty with ram in bue, and ataxia on fnf and hks in all extremities.,station: romberg sign present.,gait: unsteady, wide-based, with notable difficulty on tw, tt and hw.,reflexes: 2/2 bue, 0/1 patellae, trace at both archilles, plantars responses were flexor, bilaterally.,gen exam: unremarkable.,course:, csf analysis by lumbar puncture, 10/31/94: protein 131mg/dl (normal 15-45), albumin 68 (normal 14-20), igg10mg/dl (normal <6.2), igg index -o.1mg/24hr (normal),,no oligoclonal bands seen, wbc 33 (19lymphocytes, 1 neutrophil), rbc 29, glucose 13, cultures (bacteria, fungal, afb) were negative, crytococcal ag negative. the elevated csf total protein, igg, and albumin suggested breakdown of the blood brain barrier or blockage of csf flow. the normal igg synthesis rate and lack of oligoclonal banding did not suggest demylination. a second csf analysis on 11/2/94 revealed similar findings; and in addition anti-purkinje cell and anti-neuronal antibodies (yo and ho) were not found; beta-2 microglobulin was 1.8 (normal); histoplasmosis ag negative. serum ace, spep, urine histoplasmin were negative.,neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the mmpi (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. severe defects in memory, fine motor skills, and constructional praxis were noted.,chest-abdominal-pelvic ct scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the rmca, laca and left aica distributions. it was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of iv steroids. temporal artery biopsy was unremarkable.,she underwent multiple mri brain scans at uihc: 11/4/94, 11/9/94, 11/16/94. all scans consistently showed increase in t2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. these areas did not enhance with gadolinium contrast. these findings were felt most suggestive of glioma.,she underwent left temporal lobe brain biopsy on 11/10/94: this study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. little sign of vasculopathy or tumor was found. bacterial, fungal , hsv, cmv and afb cultures were negative. hsv, and vzv antigen was negative.,her neurological state progressively worsened throughout her hospital stay. by time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required ngt feeding and 24hour supportive care. she was made dnr after family request prior to transfer to a care facility.

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

preoperative diagnosis:, torn rotator cuff, right shoulder.,postoperative diagnoses:,1. torn rotator cuff, right shoulder.,2. subacromial spur with impingement syndrome, right shoulder.,procedure performed:,1. diagnostic arthroscopy with subacromial decompression.,2. open repair of rotator cuff using three panalok suture anchors.,anesthesia: , general.,complications: , none.,estimated blood loss: ,approximately 200 cc.,intraoperative findings: , there was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity. there is moderate amount of synovitis noted throughout the glenohumeral joint. there is a small subacromial spur noted on the very anterolateral border of the acromion.,history: , this is a 62-year-old female who previously underwent a repair of rotator cuff. she continued to have pain within the shoulder. she had a repeat mri performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. she wished to proceed with a repair. all risks and benefits of the surgery were discussed with her at length. she was in agreement with the above treatment plan.,procedure: , on 08/21/03, she was taken to the operative room at abcd general hospital. she was placed supine on the operating table. general anesthesia was applied by the anesthesiology department. she was placed in the modified beachchair position. her upper extremity was sterilely prepped and draped in usual fashion. a stab incision was made in the posterior aspect of the glenohumeral joint. a camera was placed in the joint and was insufflated with saline solution. intraoperative pictures were obtained and the above findings were noted. a second port site was initiated anteriorly. through this a probe was placed and the intraarticular structures were palpated and found to be intact. a tear of the inner surface of the rotator cuff was identified. the camera was then taken to the subacromial space. a straight lateral portal was also used and a shaver was placed into the subacromial space. further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed. the edges of the rotator cuff were then debrided. the camera was then removed and the shoulder was suction and dried. a lateral incision was made over the anterolateral border of the acromion. subcuticular tissues were carefully dissected. hemostasis was controlled with electrocautery. the deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur. a trough was then made in the greater tuberosity using the rongeur. two panalok anchors were then placed within the trough and weaved through the suture and third panalok anchor was placed medial to the trough and weaved through the rotator cuff. the ends of the suture were tied down from the fixating the rotator cuff within the trough. the rotator cuff was then further oversewed using the panalok suture. the wound was then copiously irrigated and it was then suction dried. the deltoid muscle was reapproximated using #1 vicryl. a continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control. the subcutaneous tissues were reapproximated with #2-0 vicryl. the skin was closed with #4-0 pds running subcuticular stitch. sterile dressing was applied to the upper extremity. she was then placed in a shoulder immobilizer. she was transferred to the recovery room in apparent stable and satisfactory condition. prognosis for this patient was guarded. she will begin pendulum exercises postoperative day #3. she will follow back in the office in 10 to 14 days for reevaluation. physical therapy initiated approximately six weeks postoperatively.

preoperative diagnoses: , right lumbosacral radiculopathy secondary to lumbar spondylolysis.,postoperative diagnoses: , right lumbosacral radiculopathy secondary to lumbar spondylolysis.,operation performed:,1. right l4 and l5 transpedicular decompression of distal right l4 and l5 nerve roots.,2. right l4-l5 and right l5-s1 laminotomies, medial facetectomies, and foraminotomies, decompression of right l5 and s1 nerve roots.,3. right l4-s1 posterolateral fusion with local bone graft.,4. left l4 through s1 segmental pedicle screw instrumentation.,5. preparation harvesting of local bone graft.,anesthesia: , general endotracheal.,preparation:, povidone-iodine.,indication: , this is a gentleman with right-sided lumbosacral radiculopathy, mri disclosed and lateral recess stenosis at the l4-5, l5-s1 foraminal narrowing in l4 and l5 roots. the patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain. the patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak. the patient is understanding and agreed to proceed and signed the consent.,procedure: , the patient was brought to the operating room, peripheral venous lines were placed. general anesthesia was induced. the patient was intubated. foley catheter was in place. the patient laid prone onto the osi table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped. a previous incision was infiltrated with local and incised with a scalpel. the posterior spine on the right side was exposed in routine fashion along with transverse processes in l4-l5 in the sacral ala. laminotomies were then performed at l4-l5 and l5-s1 in a similar fashion using midas rex drill with am8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone. the thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm kerrison, bone was harvested throughout to be used for bone grafting. the l5 and s1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints. transpedicular approaches were carried out for both l4 and l5 roots working lateral to medial and medial to lateral with foraminotomies, l4-l5 roots were extensively decompressed. pars interarticularis were maintained. using angled 2-mm kerrisons hypertrophied ligamentum flavum, the superior facet of s1 and l5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise. pedicle screws were placed l4-l5 and s1 on the right side. initial hole began with midas rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe. it showed no penetration outside the pedicle vertebral body. at l4-l5 5.5 x 45 mm screws were placed and at s1 5.5 x 40 mm screw was placed. good bone purchase was obtained. gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from l4 to s1. traction was applied between the l4-l5, l5-s1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots. prior to placement of bmp, the wound was irrigated with antibiotic irrigation. medium hemovac drain was placed in the depth of wound, brought out through a separate stab incision. deep fascia was closed with #1 vicryl, subcutaneous fascia with #1 vicryl, and subcuticular with 2-0 vicryl. skin was stapled. the drain was sutured in place with 2-0 vicryl and connected to closed drain system. the patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition. the patient tolerated the procedure well without apparent complication. final sponge and needle counts are correct. estimated blood loss 600 ml.,the patient received 200 ml of cell saver blood back.

sample address,re: mrs. sample patient,dear sample doctor:,i had the pleasure of seeing your patient, mrs. sample patient , in my office today. mrs. sample patient is a 48-year-old, african-american female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. the patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,past medical history:, significant for hypertension and diabetes.,past surgical history:, the patient denies any past surgical history.,medications:, the patient takes cardizem cd 240-mg. the patient also takes eye drops.,allergies:, the patient denies any allergies.,social history:, the patient smokes about a pack a day for more than 25 years. the patient drinks alcohol socially.,family history:, significant for hypertension and strokes.,review of systems:, the patient does have a good appetite and no weight loss. she does have intermittent rectal bleeding associated with irritation in the rectal area. the patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,the patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,the patient is chronically constipated.,physical examination:, this is a 48 year-old lady who is awake, alert and oriented x 3. she does not seem to be in any acute distress. her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. heent is normocephalic, atraumatic. sclerae are non-icteric. her neck is supple, no bruits, no lymph nodes. lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. the cardiovascular system has a regular rate and rhythm, no murmurs. the abdomen is soft and non-tender. bowel sounds are positive and no organomegaly. extremities have no edema.,impression:, this is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. the patient is chronically constipated.,1. rule out colon cancer.,2. rule out colon polyps. ,3. rule out hemorrhoids, which is the most likely diagnosis.,recommendations:, because of the patient's age, the patient will need to have a complete colonoscopy exam.,the patient will also need to have a cbc check and monitor.,the patient will be scheduled for the colonoscopy at sample hospital and the full report will be forwarded to your office.,thank you very much for allowing me to participate in the care of your patient.,sincerely yours,,sample doctor, md

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.

reason for visit: , the patient referred by dr. x for evaluation of her possible tethered cord.,history of present illness:, briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. the last surgery was in 03/95. she did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring advil, motrin as well as tylenol pm.,denies any new bowel or bladder dysfunction or increased sensory loss. she had some patchy sensory loss from l4 to s1.,medications: , singulair for occasional asthma.,findings: , she is awake, alert, and oriented x 3. pupils equal and reactive. eoms are full. motor is 5 out of 5. she was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus. there is no evidence of clonus. there is diminished sensation from l4 to s1, having proprioception.,assessment and plan: , possible tethered cord. i had a thorough discussion with the patient and her parents. i have recommended a repeat mri scan. the prescription was given today. mri of the lumbar spine was just completed. i would like to see her back in clinic. we did discuss the possible symptoms of this tethering.

admitting diagnoses:,1. respiratory distress.,2. reactive airways disease.,discharge diagnoses:,1. respiratory distress.,2. reactive airways disease.,3. pneumonia.,history of present illness: , the patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of uri symptoms, then had an abrupt onset of cough and increased work of breathing. child was brought to children's hospital and received nebulized treatments in the er and the hospitalist service was contacted regarding admission. the patient was seen and admitted through the emergency room.,he was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress. he also received inhaled as well as systemic corticosteroids. an x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading. the patient was not started on any antibiotics and his fever resolved. however, the crp was relatively elevated at 6.7. the cbc was normal with a white count of 9.6; however, the bands were 84%. given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and zithromax.,he was taken off of continuous and he was not on room air all night. in the morning, he still had some bilateral wheezing, but no tachypnea.,discharge physical examination: , ,general: no acute distress, running around the room.,heent: oropharynx moist and clear.,neck: supple without lymphadenopathy, thyromegaly or masses.,chest: bilateral basilar wheezing. no distress.,cardiovascular: regular rate and rhythm. no murmurs noted. well perfused peripherally.,abdomen: bowel sounds present. the abdomen is soft. there is no hepatosplenomegaly, no masses. nontender to palpation.,genitourinary: deferred.,extremities: warm and well perfused.,discharge instructions:, as follows:,1. activity, regular.,2. diet is regular.,3. follow up with dr. x in 2 days.,discharge medications:,1. xopenex mdi 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2. qvar 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3. amoxicillin 550 mg p.o. twice daily for 10 days.,4. zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,total time for this discharge 37 minutes.

technique: , sequential axial ct images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 cc optiray 320 intravenous contrast.,findings:, scans through the base of the brain are unremarkable. the oropharynx and nasopharynx are within normal limits. the airway is patent. the epiglottis and epiglottic folds are normal. the thyroid, submandibular, and parotid glands enhance homogenously. the vascular and osseous structures in the neck are intact. there is no lymphadenopathy. the visualized lung apices are clear.,impression: ,no acute abnormalities.

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

reason for consult:, evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,history of present illness: , this is a 50-year-old male who was transferred from sugar land er to abcd hospital for admission to the micu for acute alcohol withdrawal. the patient had been on a drinking binge for the past 12 days prior to admission and had not been eating. he reported that he called 911 secondary to noticing bilious vomiting and dry heave. the patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years. he has been away from work secondary to alcohol cravings and drinking. he has also experienced marital and family conflict as a result of his drinking habit. on average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily. he reports a history of withdrawal symptoms, but denied history of withdrawal seizures. his longest period of sobriety was one year, and this was due to the assistance of attending aa meetings. the patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit. he reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits. he denies depressive symptoms. he denies any psychotic symptoms or perceptual disturbances. there are no active symptoms of withdrawal at this time.,past psychiatric history: , there are no previous psychiatric hospitalizations or evaluations. the patient denies any history of suicidal attempts. there is no history of inpatient rehabilitation programs. he has attended aa for periodic moments throughout the past few years. he has been treated with antabuse before.,past medical history:, the patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,medications: , his outpatient medications include lotrel 30 mg p.o. q.a.m. and restoril 30 mg p.o. q.h.s.,inpatient medications are vitamin supplements, potassium chloride, lovenox 40 mg subcutaneously daily, lactulose 30 ml q.8h., nexium 40 mg iv daily, ativan 1 mg iv p.r.n. q.6-8h.,allergies:, no known drug allergies.,family history: , distant relatives with alcohol dependance. no other psychiatric illnesses in the family.,social history:, the patient has been divorced twice. he has two daughters one from each marriage, ages 15 and 22. he works as a geologist at petrogas. he has limited contact with his children. he reports that his children's mothers have turned them against him. he and his wife have experienced marital discord secondary to his alcohol use. his wife is concerned that he may loose his job because he has skipped work before without reporting to his boss. there are no other illicit drugs except alcohol that the patient reports.,physical examination:, vital signs: temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,mental status examination:, this is a well-groomed male. he appears his stated age. he is lying comfortably in bed. there are no signs of emotional distress. he is pleasant and engaging. there are no psychomotor abnormalities. no signs of tremulousness. his speech is with normal rate, volume, and inflection. mood is reportedly okay. affect euthymic. thought content, no suicidal or homicidal ideations. no delusions. thought perception, there are no auditory or visual hallucinations. thought process, logical and goal directed. insight and judgment are fair. the patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,laboratory data:, cbc: wbc 5.77, h&h 14 and 39.4 respectively, and platelets 102,000. bmp: sodium 140, potassium 3, chloride 104, bicarbonate 26, bun 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, pt 13.4, and inr 1.0. lfts: alt 64, ast 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2. pfts within normal limits.,imaging:, cat scan of the abdomen and pelvis reveals esophagitis and fatty liver. no splenomegaly.,assessment:, this is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver. the patient currently has no signs of withdrawal. the patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use. the patient had severe insomnia that is likely secondary to alcohol use. currently, there are no signs of primary anxiety disorder in this patient.,diagnoses:, axis i: alcohol dependence.,axis ii: deferred.,axis iii: fatty liver, esophagitis, and hypertension.,axis iv: marital discord, estranged from children.,axis v: global assessment of functioning equals 55.,recommendations:,1. continue to taper off p.r.n. ativan and discontinue all ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient. discontinue outpatient restoril. the patient has been informed of the hazards of using benzodiazepines along with alcohol.,2. continue alcoholics anonymous meetings to maintain abstinence.,3. recommend starting campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4. supplement with multivitamin, thiamine, and folate upon discharge and before. marital counseling strongly advised as well as individual therapy for patient once sobriety is reached. referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5. alcohol education and counseling provided during consultation.,6. trazodone 50 mg p.o. q.h.s. for insomnia.,7. follow up with pcp in 1 to 2 weeks.

reason for consultation: , possible free air under the diaphragm.,history of present illness: , the patient is a 77-year-old female who is unable to give any information. she has been sedated with ativan and came into the emergency room obtunded and unable to give any history. on a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,past medical history: , significant for alcohol abuse. unable to really gather any other information because she is so obtunded.,past surgical history: ,looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and tah/bso.,medications:, unable to evaluate.,allergies: , unable to evaluate.,social history: ,significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,review of systems: , unable to obtain.,physical exam,vital signs: temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,general: she is a very obtunded female who upon arousal is not able to provide any information of any use.,heent: atraumatic.,neck: soft and supple.,lungs: bilaterally diminished.,heart: regular.,abdomen: soft, and with deep palpation i am unable to arouse the patient, unable to elicit any tenderness.,laboratory studies: , show a normal white blood cell count with no shift. elevated ast at 138, with a normal alt at 38. alkaline phosphatase of 96, bilirubin 0.8. sodium is 107, with 68 chloride and potassium of 2.8.,x-ray of the chest shows the possibility of free air; therefore, a ct scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology. the etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,assessment: , no intra-abdominal pathology.,plan:, have her admitted to the medical service for treatment of her hyponatremia.

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

procedure in detail: , following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. the olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. withdrawal notes an otherwise normal descending, rectosigmoid and rectum. retroflexion noted no abnormality of the internal ring. no hemorrhoids were noted. withdrawal from the patient terminated the procedure.

procedure: , right sacral alar notch and sacroiliac joint/posterior rami radiofrequency thermocoagulation.,anesthesia: ,local sedation.,vital signs: , see nurse's notes.,complications: , none.,details of procedure: , int was placed. the patient was in the operating room in the prone position. the back prepped with betadine. the patient was given sedation and monitored. under fluoroscopy, the right sacral alar notch was identified. after placement of a 20-gauge, 10 cm smk needle into the notch, a positive sensory, negative motor stimulation was obtained. following negative aspiration, 5 cc of 0.5% of marcaine and 20 mg of depo-medrol were injected. coagulation was then carried out at 90oc for 90 seconds. the smk needle was then moved to the mid-inferior third of the right sacroiliac joint. again the steps dictated above were repeated.,the above was repeated for the posterior primary ramus branch right at s2 and s3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injected and coagulation as above.,there were no complications. the patient was returned to outpatient recovery in stable condition.

identifying data:, the patient is a 36-year-old caucasian male.,chief complaint:, the patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,history of present illness:, the patient has been receiving services at this facility previously, under the care of abc, m.d., and later xyz, m.d. historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. he first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. in the past, probably in high school, the patient recalled being more figidity than now. he tensed to feel anxious. sleep has been highly variable. he will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. appetite has been good. he has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking adderall. he tends to feel depressed. his energy level is "better now," but this was very problematic in the past. he has problems with motivation. in the past, he had passing thoughts of suicide, but this is no longer a problem.,psychiatric history:, the patient has never been hospitalized for psychiatric purposes. his only treatment has been at this facility. he tried adderall for a time, and it helped, but he became hypertensive. lunesta is effective for his insomnia issues. effexor has helped to some degree. he has been prescribed provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. he sometimes takes the other half of the tablet in the afternoon.

operation performed:, full mouth dental rehabilitation in the operating room under general anesthesia.,preoperative diagnoses: ,1. severe dental caries.,2. hemophilia.,postoperative diagnoses: ,1. severe dental caries.,2. hemophilia.,3. nonrestorable teeth.,complications: , none.,estimated blood loss: , minimal.,duration of surgery: ,1 hour and 22 minutes.,brief history: ,the patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on tuesdays and thursdays and he has a mediport. mom reported history of high fever after surgery and he has one seizure previously. he has history of trauma to his front teeth and physician put him on antibiotics. he was only cooperative for having me do a visual examination on his anterior teeth. visual examination revealed severe dental caries and dental abscess from tooth #e and his maxillary anterior teeth needed to be extracted. due to his young age and hemophilia, i felt that he would be best served to be taken to the hospital operating room.,other preparation: ,the child was brought to the hospital day surgery accompanied by his mother. there, i met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment. after all her questions and concerns were addressed, she gave her informed consent to proceed with treatment. the patient's history and physical examination was reviewed. he was given factor for appropriately for his hemophilia prior to being taken back to the operating room. once he was cleared by anesthesia, the child was taken back to the operating room.,operative procedure: ,the patient was placed on the surgical table in the usual supine position with all extremities protected. anesthesia was induced by mask. the patient was then intubated with an oral tube and the tube was stabilized. the head was wrapped and iv was started. the head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath. a moist continuous throat pack was placed beyond tonsillar pillars. plastic lip and cheek retractors were then placed. preoperative clinical photographs were taken. two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph. after the radiographs were taken, the lead shield was removed.,prophylaxis was then performed using a prophy cup and fluoridated prophy paste. the patient's teeth were rinsed well. the patient's oral cavity was suctioned clean. clinical and radiographic examination followed and areas of decay were noted. during the restorative phase, these areas of decay were incidentally removed. entry was made to the level of the dental-enamel junction and beyond as necessary to remove it. final caries removal was confirmed upon reaching hard, firm and sound dentin.,teeth restored with composite ___________ bonded with a one-step bonding agent. teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement. non-restorable primary teeth would be extracted. the caries were extensive and invaded the pulp tissues, pulp therapy was initiated using viscostat and then irm pulpotomies. teeth treated in such a manner would then be crowned with stainless steel crowns.,upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris. the original treatment plan was verified with the actual treatment provided. postoperative clinical photographs were then taken. the continuous gauze throat pack was removed with continuous suction with visualization. topical fluoride was then placed on the teeth. at the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,findings: , this young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene. all primary teeth were present. dental carries were present on the following teeth: tooth b, ol caries, tooth c, m, l, s caries, tooth b, caries on all surfaces, tooth e caries on all surfaces, tooth f caries on all surfaces, tooth t caries on all surfaces, tooth h, lingual and facial caries, tooth i, caries on all surfaces, tooth l caries on all surfaces, and tooth s, all caries. the remainder of his teeth and soft tissues were within normal limits. the following restoration and procedures were performed. tooth b, ol amalgam, tooth c, m, l, s composite, tooth d, e, f, and g were extracted, tooth h, and l and separate f composite. tooth i is stainless steel crown, tooth l pulpotomy and stainless steel crown and tooth s no amalgam. sutures were also placed at extraction site d, e, s, and g.,conclusion: ,the mother was informed of the completion of the procedure. she was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care. she is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother. she was also given prescription for tylenol with codeine elixir for postoperative pain control.,

description:, the patient was placed in the supine position and was prepped and draped in the usual manner. the left vas was grasped in between the fingers. the skin and vas were anesthetized with local anesthesia. the vas was grasped with an allis clamp. skin was incised and the vas deferens was regrasped with another allis clamp. the sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens. the portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side. the incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,a similar procedure was carried out on the right side. dry sterile dressings were applied and the patient put on a scrotal supporter. the procedure was then terminated.

preoperative diagnosis:, critical left carotid stenosis.,postoperative diagnosis: , critical left carotid stenosis.,procedure performed:, left carotid endarterectomy with endovascular patch angioplasty.,anesthesia:, cervical block.,gross findings: ,the patient is a 57-year-old black female with chronic renal failure. she does have known critical carotid artery stenosis. she wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by dr. x to perform cardiac catheterization. she was admitted to the hospital yesterday with chest pain. she has been considered for coronary artery bypass grafting. i have been asked to address the carotid stenosis, left being more severe, this was addressed first. intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery. the internal carotid artery is quite torturous. the external carotid artery was occluded at its origin. when the endarterectomy was performed, the external carotid artery back-bled nicely. the internal carotid artery had good backflow bleeding noted.,operative procedure: , the patient was taken to the or suite and placed in the supine position. then neck, shoulder, and chest wall were prepped and draped in appropriate manner. longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape. during the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them. also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved. there was some inflammation above the carotid bulb, but this was not problematic.,the patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time. the internal carotid artery is controlled with heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with heifitz clips. the common carotid artery was controlled with profunda clamp. the patient remained neurologically intact. a longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery. this was extended across the lobe on to the internal carotid artery. an endarterectomy was then performed. the ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline. as mentioned before, the internal carotid artery is quite torturous. this was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 prolene suture.,the wound was copiously irrigated, rather an endovascular patch was then brought on to the field. this was cut to shape and length. this was sutured in place with continuous running #6-0 prolene suture. the suture line began at both sites. the suture was tied in the center along the anterior and posterior walls. prior to completing the closure, the common carotid artery was flushed. the internal carotid artery permitted to back bleed. the clamp was placed after completing the closure. the clamp was placed at the origin of the internal carotid artery. flow was first directed into the external carotid artery then into the internal carotid artery. the patient remained neurologically intact. topical ________ gelfoam was utilized. of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin. the wound was copiously irrigated with antibiotic solution. sponge, needle, and all counts were correct. all surgical sites were inspected. good hemostasis noted. the incision was closed in layers with absorbable suture. stainless steel staples approximated skin. sterile dressings were applied. the patient tolerated the procedure well, grossly neurologically intact.

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

exam: ,bilateral diagnostic mammogram, left breast ultrasound and biopsy.,history: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. the patient has a family history of breast cancer within her mother at age 58. patient denies personal history of breast cancer.,technique and findings: ,craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. an additional lateromedial projection of the right breast was obtained. the breasts demonstrate heterogeneously-dense fibroglandular tissue. within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter. no additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen. multiple additional benign-appearing calcifications are visualized bilaterally. skin overlying both breasts is unremarkable.,bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder. this mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow. this may represent benign fibrous tissue or a lipoma.,additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter. at this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,the risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast. informed consent was obtained. the lesion was re-localized under ultrasound guidance. the left breast was prepped and draped in the usual sterile fashion. 2% lidocaine was administered locally for anesthesia. additional lidocaine with epinephrine was administered around the distal aspect of the lesion. a small skin nick was made. color doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides. the lateral to medial approach was performed with an 11-gauge mammotome device. the device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture. two core biopsies were obtained. the third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma. arterial blood was visualized exiting the access site. a biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage. therefore, the mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved. postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter. the left breast was re-cleansed with a chloraprep, and a pressure bandage and ice packing were applied to the left breast. the patient was observed in the ultrasound department for the following 30 minutes without complaints. the patient was subsequently discharged with information and instructions on utilizing the ice bandage. the obtained specimens were sent to pathology for further analysis.,impression:,1. a mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a mammotome core biopsy instrument, and multiple core biopsies were obtained. transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma. pressure was applied until hemostasis was achieved. the patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition. the core biopsies were submitted to pathology for further analysis.,2. small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3. suspicious mammographic findings. the circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied. further pathologic analysis is pending.,birads classification 4 - suspicious findings.,mammography information:,1. a certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. these images were obtained with fda-approved digital mammography equipment, and icad secondlook software version 7.2 was utilized.

preoperative diagnoses:,1. gastroesophageal reflux disease.,2. hiatal hernia.,postoperative diagnoses:,1. gastroesophageal reflux disease.,2. hiatal hernia.,3. enterogastritis.,procedure performed: ,esophagogastroduodenoscopy, photography, and biopsy.,gross findings: , the patient has a history of epigastric abdominal pain, persistent in nature. she has a history of severe gastroesophageal reflux disease, takes pepcid frequently. she has had a history of hiatal hernia. she is being evaluated at this time for disease process. she does not have much response from protonix.,upon endoscopy, the gastroesophageal junction is approximately 40 cm. there appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia. there is no advancement of the gastric mucosa up into the lower one-third of the esophagus. however there appeared to be inflammation as stated previously in the gastroesophageal junction. there was some mild inflammation at the antrum of the stomach. the fundus of the stomach was within normal limits. the cardia showed some laxity to the lower esophageal sphincter. the pylorus is concentric. the duodenal bulb and sweep are within normal limits. no ulcers or erosions.,operative procedure: , the patient is taken to the endoscopy suite, prepped and draped in the left lateral decubitus position. the patient was given iv sedation using demerol and versed. olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus. using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted. panendoscope was slowly withdrawn carefully examining the lumen of the bowel. photographs were taken with the pathology present. biopsy was obtained of the antrum of the stomach and also clo test. the biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult barrett's esophagitis. air was aspirated from the stomach and the panendoscope was removed. the patient sent to recovery room in stable condition.

general: negative for any nausea, vomiting, fevers, chills, or weight loss.,neurologic: negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,heent: negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,cardiac: negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,pulmonary: negative for any shortness of breath, wheezing, copd, or tb exposure.,gastrointestinal: negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,genitourinary: negative for any dysuria, hematuria, incontinence.,integumentary: negative for any rashes, cuts, insect bites.,rheumatologic: negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,hematologic: negative for any abnormal bruising, frequent infections or bleeding.

preoperative diagnosis:, displace subcapital fracture, left hip.,postoperative diagnosis: , displace subcapital fracture, left hip.,procedure performed: , austin-moore bipolar hemiarthroplasty, left hip utilizing a medium fenestrated femoral stem with a medium 0.8 mm femoral head, a 50 mm bipolar cup.,procedure: , the patient was taken to or #2, administered a subarachnoid block anesthetic and was then positioned in the right lateral decubitus position on the beanbag on the operative table. the right lower extremity was protectively padded. the left leg was propped with multiple blankets. the hip was then prepped and draped in the usual manner. a posterior incision was made on the posterolateral aspect of the left hip down to the skin and subcutaneous tissues. hemostasis was achieved utilizing electrocautery. gluteus fascia was incised in line with a skin incision and the muscle was split posteriorly. the external rotators were identified after removal of the trochanteric bursa. hemostat was utilized to separate the external rotators from the underlying capsule, they were then transected off from their attachment at the posterior intertrochanteric line. they were then reflected distally. the capsule was then opened in a t-fashion utilizing the cutting cautery. fraction hematoma exuded from the hip joint. the cork screw was then impacted into the femoral head and it was removed from the acetabulum. bone fragments were removed from the neck and acetabulum. the acetabulum was then inspected and noted to be free from debris. the proximal femur was then delivered into the wound with the hip internally rotated.,a mortise chisel was then utilized to take the cancellous bone from the proximal femur. the t-handle broach was then passed down the canal. the canal was then sequentially broached up to a medium broach. the calcar was then plained with the hand plainer. the trial components were positioned into place. the medium component fit fairly well with the medium 28 mm femoral head. once the trial reduction was performed, the hip was taken through range of motion. there was physiologic crystalling with longitudinal traction. there was no tendency towards dislocation with flexion of the hip past 90 degrees. the trial implants were then removed. the acetabulum was then copiously irrigated with gentamicin solution and suctioned dry. the medium fenestrated femoral stem was prepared by placing a large segment of bone from the femoral head into the fenestration making it a little larger than the width of the implant to provide a press fit. the implant was then impacted into place. the 28 mm femoral head was impacted on the mortise stapler of the femoral stem followed by placement of the 50 mm bipolar cup. the acetabulum was once again inspected, was free of debris. the hip was reduced. it was taken through full range of motion. there was no tendency for dislocation. the wound was copiously irrigated with gentamicin solution. the capsule was then repaired with interrupted #1 ethibond suture. external rotators were then reapproximated to the posterior intertrochanteric line utilizing #1 ethibond in a modified kessler type stitch. the wound was once again copiously irrigated with gentamicin solution and suctioned dry. gluteus fascia was approximated with interrupted #1 ethibond. subcutaneous layers were approximated with interrupted #2-0 vicryl and skin approximated with staples. a bulky dressing was applied to the wound. the patient was then transferred to the hospital bed, an abductor pillow was positioned into place. circulatory status was intact to the extremity at completion of the case.

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

chief complaint:, urinary retention.,history of present illness: , this is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time. most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration. he was seen by urology again at this visit for urinary retention. he had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08. cystoscopy showed at that time obstructive bph. he was started on flomax at the time of discharge from the hospital. during the most recent readmission on 02/04/08, he went back into urinary retention and he had had a foley placed at the outside hospital.,review of systems:, positive for blurred vision, nasal congestion, and occasional constipation. denies chest pain, shortness of breath or any rashes or lesions. all other systems were reviewed and found to be negative.,past medical history:,1. end-stage renal disease, now status post deceased donor kidney transplant in 12/07.,2. hypertension.,3. history of nephrolithiasis.,4. gout.,5. bph.,6. djd.,past surgical history:,1. deceased donor kidney transplant in 12/07.,2. left forearm and left upper arm fistula placements.,family history: ,significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family. he does not know whether his father side of the family had any history of prostate cancer.,home medications:,1. norvasc.,2. toprol 50 mg.,3. clonidine 0.2 mg.,4. hydralazine.,5. flomax.,6. allopurinol.,7. sodium bicarbonate.,8. oxybutynin.,9. coumadin.,10. aspirin.,11. insulin 70/30.,12. omeprazole.,13. rapamune.,14. cellcept.,15. prednisone.,16. ganciclovir.,17. nystatin swish and swallow.,18. dapsone.,19. finasteride.,allergies:, no known drug allergies.,physical examination:,general: this is a well-developed, well-nourished male, in no acute distress. vital signs: temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds. lungs: clear to auscultation bilaterally. cardiovascular: regular rate and rhythm with a 3/6 systolic murmur. abdomen: right lower quadrant incision site scar well healed. nontender to palpation. liver and spleen not enlarged. no hernias appreciated. penis: normal male genitalia. no lesions appreciated on the penis. previous dre showed the prostate of approximately 40 grams and no nodules. foley in place and draining clear urine.,the patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder. he spontaneously voided without the foley 110 ml.,assessment and plan: ,this is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07. he passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again. we discussed with mr. barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at mcg and has been set up for followup in 6 weeks. he was also given a prescription for 6 months of flomax and proscar. he did not have a psa drawn today as he had a catheter in place, therefore his psa could be falsely elevated. he will have psa level drawn either just before his visit for followup.

reason for consultation: ,management for infection of the left foot.,history: , the patient is a 26-year-old short caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot. he noticed a small dark spot. he did not remember having had any injuries to that area specifically no puncture wounds. he had not been doing any outdoor works or activities. no history of working outdoors, has not been to the beach or to the lake, has not been out of town. his swelling progressed so he went to see dr. x 4 days ago. the area was debrided in the office and he was placed on keflex. it was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies. his foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening. ancef and cipro were prescribed today. he denies any fever, chills, red streaks, lymphadenitis. he had a tetanus shot in 2002 most recently. he had childhood asthma. he uses alcohol socially. he works full time. he is an electrician.,allergies:, accutane.,physical examination,general: well-developed, well-nourished adult caucasian male in no acute distress.,vital signs: his weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, o2 sat 98% on room air.,heent: mouth unremarkable.,neck: supple.,lungs: clear.,heart: regular rate rhythm. no murmur or gallop.,abdomen: soft and nontender.,extremities: left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema. there is bloodied blister around it. the area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema. there is some mild intertrigo between the fourth and fifth left toes. palpable pedal pulses. leg unremarkable. no femoral or inguinal lymphadenopathy.,laboratory: , labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, bun of 16, glucose 110. calcium, ferritin, albumin, bilirubin, alt, ast, alkaline phosphatase are normal. pt and ptt normal and the sed rate was 35 mm per hour.,impression: ,abscess of the left foot, etiology unclear at this time. possibility of foreign body.,recommendations/plan: , he is going to be discharged in about half-an-hour. cultures, gram stain, fungal cultures, and smear to be obtained. i have changed his antibiotic to vancomycin plus maxipime. he is currently on tetanus immunizations so no need for booster at this time.,

preoperative diagnosis: , hypoxia and increasing pulmonary secretions.,postoperative diagnosis: , hypoxia and increasing pulmonary secretions.,operation: , bronchoscopy.,anesthesia: , moderate bedside sedation.,complications:, none.,findings:, abundant amount of clear thick secretions throughout the main airways.,indications:, the patient is a 43-year-old gentleman who has been in the icu for several days following resection of small bowel for sequelae of smv occlusion. this morning, the patient developed worsening hypoxia with abundant sputum production requiring frequent suctioning from his et tube. the patient also had new-appearing atelectasis versus infiltrates in the right lower lobe of his lung on chest x-ray. given these findings, it was felt that bronchoscopy could further define source of secretions and send more appropriate specimen for culture if need be.,operation:, the patient was given additional fentanyl, versed as well as paralytics for the procedure. small bronchoscope was inserted through the et tube and to the trachea to the level of carina. there was noted to be thick clear secretions adherent to the trachea walls as well as into the right mainstem bronchus. extensive secretions extended down into the secondary airways. this was lavaged with saline and suctioned dry. there is no overt specific occlusion of airways, nor was there any purulent-appearing sputum. the bronchoscope was then advanced into the left mainstem bronchus, and there was noted to be a small amount of similar-appearing secretions which was likewise suctioned and cleaned. the bronchoscope was removed, and the patient was increased to peep of 10 on the ventilator. please note that prior to starting bronchoscopy, he was pre oxygenated with 100% o2. the patient tolerated the procedure well and lavage specimen was sent for gram stain as well as routine culture.

preoperative diagnosis: , achilles tendon rupture, left lower extremity.,postoperative diagnosis: , achilles tendon rupture, left lower extremity.,procedure performed:, primary repair left achilles tendon.,anesthesia: , general.,complications: , none.,estimated blood loss: , minimal.,total tourniquet time: ,40 minutes at 325 mmhg.,position:, prone.,history of present illness: ,the patient is a 26-year-old african-american male who states that he was stepping off a hilo at work when he felt a sudden pop in the posterior aspect of his left leg. the patient was placed in posterior splint and followed up at abc orthopedics for further care.,procedure:, after all potential complications, risks, as well as anticipated benefits of the above-named procedure were discussed at length with the patient, informed consent was obtained. the operative extremity was then confirmed with the patient, the operative surgeon, department of anesthesia, and nursing staff. while in this hospital, the department of anesthesia administered general anesthetic to the patient. the patient was then transferred to the operative table and placed in the prone position. all bony prominences were well padded at this time.,a nonsterile tourniquet was placed on the left upper thigh of the patient, but not inflated at this time. left lower extremity was sterilely prepped and draped in the usual sterile fashion. once this was done, the left lower extremity was elevated and exsanguinated using an esmarch and the tourniquet was inflated to 325 mmhg and kept up for a total of 40 minutes. after all bony and soft tissue land marks were identified, a 6 cm longitudinal incision was made paramedial to the achilles tendon from its insertion proximal. careful dissection was then taken down to the level of the peritenon. once this was reached, full thickness flaps were performed medially and laterally. next, retractor was placed. all neurovascular structures were protected. a longitudinal incision was then made in the peritenon and opened up exposing the tendon. there was noted to be complete rupture of the tendon approximately 4 cm proximal to the insertion point. the plantar tendon was noted to be intact. the tendon was debrided at this time of hematoma as well as frayed tendon. wound was copiously irrigated and dried. most of the ankle appeared that there was sufficient tendon links in order to do a primary repair. next #0 pds on a taper needle was selected and a krackow stitch was then performed. two sutures were then used and tied individually ________ from the tendon. the tendon came together very well and with a tight connection. next, a #2-0 vicryl suture was then used to close the peritenon over the achilles tendon. the wound was once again copiously irrigated and dried. a #2-0 vicryl sutures were then used to close the skin and subcutaneous fashion followed by #4-0 suture in the subcuticular closure on the skin. steri-strips were then placed over the wound and the sterile dressing was applied consisting of 4x4s, kerlix roll, sterile kerlix and a short length fiberglass cast in a plantar position. at this time, the department of anesthesia reversed the anesthetic. the patient was transferred back to hospital gurney to the postanesthesia care unit. the patient tolerated the procedure well. there were no complications.

subjective:, the patient presents with mom and dad for her 1-year well child check. the family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains. normal voiding and stooling pattern. no concerns with hearing or vision. growth and development: denver ii normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development. see denver ii form in the chart.,past medical history:, allergies: none. medications: tylenol this morning in preparation for vaccines and a multivitamin daily.,family social history:, unchanged since last checkup.,review of systems:, as per hpi; otherwise negative.,objective:, weight 24 pounds 1 ounce. height 30 inches. head circumference 46.5 cm. temperature afebrile.,general: a well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,heent: atraumatic, normocephalic. anterior fontanel is closed. pupils equally round and reactive. sclerae are clear. red reflex present bilaterally. extraocular muscles intact. tms are clear bilaterally. oropharynx: mucous membranes are moist and pink. good dentition. drooling and chewing with teething behavior today. neck is supple. no lymphadenopathy.,chest: clear to auscultation bilaterally. no wheeze. no crackles. good air exchange.,cardiovascular: regular rate and rhythm. no murmur. good pulses bilaterally.,abdomen: soft, nontender. nondistended. positive bowel sounds. no mass. no organomegaly.,genitourinary: tanner i female genitalia. femoral pulses equal bilaterally. no rash.,extremities: full range of motion. no cyanosis, clubbing or edema. negative ortolani and barlow maneuver.,back: straight. no scoliosis.,integument: warm, dry and pink without lesions.,neurological: alert. good muscle tone and strength. cranial nerves ii through xii are grossly intact.,assessment and plan:,1. well 1-year-old white female.,2. anticipatory guidance. reviewed growth, diet development and safety issues as well as immunizations. will receive pediarix and hib today. discussed risks and benefits as well as possible side effects and symptomatic treatment. will also obtain a screening cbc and lead level today via fingerstick and call the family with results as they become available. gave 1-year well child checkup handout to mom and dad.,3. follow up for the 15-month well child check or as needed for acute care.

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

procedure performed: , extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,anesthesia:, peribulbar.,complications:, none.,description of procedure: ,the patient was brought to the operating room after the eye was dilated with topical mydriacyl and neo-synephrine drops. a honan balloon was placed over the eye for a period of 20 minutes at 10 mmhg. a peribulbar block was given to the eye using 8 cc of a mixture of 0.5% marcaine without epinephrine mixed with wydase plus one-half of 2% lidocaine without epinephrine. the honan balloon was then re-placed over the eye for an additional 10 minutes at 20 mmhg. the eye was prepped with a betadine solution and draped in the usual sterile fashion. a wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade, followed by instillation of 0.1 cc of preservative-free lidocaine 1% into the anterior chamber, followed by viscoelastic. a 2.8-mm keratome was used to create a self-sealing temporal corneal incision and then a bent capsulotomy needle was used to create an anterior capsular flap. the utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with bss on a cannula. phacoemulsification in a quartering-and-cracking technique was used to remove the nucleus and then the residual cortex was removed with the irrigation and aspiration unit. gentle vacuuming of the central posterior capsule was performed. the capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size with an additional keratome to allow insertion of the intraocular lens.,the intraocular lens was folded, inserted into the capsular bag and then un-folded. the trailing haptic was tucked underneath the anterior capsular rim. the lens was shown to center very well. therefore, the viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after miochol was injected into the anterior chamber to cause pupillary constriction. the wound was shown to be watertight. therefore, tobradex ointment was applied to the eye, an eye pad loosely applied and a fox shield taped firmly in place.,the patient tolerated the procedure well and left the operating room in good condition.

history of present illness: , the patient presents today as a consultation from dr. abc's office regarding the above. he was seen a few weeks ago for routine followup, and he was noted for microhematuria. due to his history of kidney stone, renal ultrasound as well as ivp was done. he presents today for followup. he denies any dysuria, gross hematuria or flank pain issues. last stone episode was over a year ago. no history of smoking. daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,creatinine 1.0 on june 25, 2008, ua at that time was noted for 5-9 rbcs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis. ivp same day revealed a calcification over the left kidney, but without bilateral hydronephrosis. the calcification previously noted on the ureter appears to be outside the course of the ureter. otherwise unremarkable. this is discussed.,impression: ,1. a 6-mm left intrarenal stone, nonobstructing, by ultrasound and ivp. the patient is asymptomatic. we have discussed surgical intervention versus observation. he indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2. microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future. urine sent for culture and sensitivity.,plan: , as above. the patient will follow up for cystoscopy, urine sent for cytology, continue hydration. call if any concern. the patient is seen and evaluated by myself.

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

history and reason for consultation:, for evaluation of this patient for colon cancer screening.,history of present illness:, mr. a is a 53-year-old gentleman who was referred for colon cancer screening. the patient said that he occasionally gets some loose stools. other than that, there are no other medical problems. ,past medical history:, the patient does not have any serious medical problems at all. he denies any hypertension, diabetes, or any other problems. he does not take any medications.,past surgical history: ,surgery for deviated nasal septum in 1996.,allergies:, no known drug allergies.,social history: ,does not smoke, but drinks occasionally for the last five years.,family history:, there is no history of any colon cancer in the family.,review of systems:, denies any significant diarrhea. sometimes he gets some loose stools. occasionally there is some constipation. stools caliber has not changed. there is no blood in stool or mucus in stool. no weight loss. appetite is good. no nausea, vomiting, or difficulty in swallowing. has occasional heartburn.,physical examination:, the patient is alert and oriented x3. vital signs: weight is 214 pounds. blood pressure is 111/70. pulse is 69 per minute. respiratory rate is 18. heent: negative. neck: supple. there is no thyromegaly. cardiovascular: both heart sounds are heard. rhythm is regular. no murmur. lungs: clear to percussion and auscultation. abdomen: soft and nontender. no masses felt. bowel sounds are heard. extremities: free of any edema.,impression: ,routine colorectal cancer screening.,recommendations:, colonoscopy. i have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. the patient agreed for it. we will proceed with it. i also explained to the patient about conscious sedation. he agreed for conscious sedation.

reason for referral: ,the patient was referred to me by dr. x of children's hospital after he was hospitalized for what eventually was diagnosed as a conversion disorder. i had met the patient and his mother in the hospital and had begun getting information regarding his symptoms and background at that time. after his discharge, the patient was scheduled to see me for followup services. this was a 90-minute intake that was completed on 10/10/2007 with the patient's mother. i reviewed with her the treatment consent form as well as the boundaries of confidentiality, and she stated that she understood these concepts.,presenting problems:, please see the inpatient hospital progress note contained in his chart for additional background information. the patient's mother reported that he continues with his conversion episodes. she noted that they are occurring approximately 6 times a day. they consist primarily of tremors, arching his back, and, by her report, doing some gang signs during the episode. she reported that the conversion reactions had decreased after his hospitalization, and he had none for 3 days, but then, they began picking up again. from information gathered from mother, it would suggest that she frequently does "status checks," where she asks him how he is doing, and that after she began checking on him more that he began having more conversion reactions. in terms of what she does when he has a conversion reaction, she reported that primarily that she tries to keep him safe. she puts a sheath under him because the carpeting is dirty. she removes any furniture, she wraps his legs together so they do not knock together, she sits with him and she gives him attention and says "calm down, breathe" and after it is over, she continues to tell him to be calm and to breathe. she denied that she gives them any more attention. i strongly encouraged her to stop doing status checks, as this likely is reinforcing the behavior. i also noted that while he certainly needs to be kept safe, that she does not want to give a lot of attention to this behavior, and that over time we will teach him ways of coping with this independently. in regards to his mood, she reported that his mood is quite good. she denied any sadness or irritability. she denied anhedonia. she reports that he is a little bit hard to get up in the morning. he is going to bed at about 11, getting up at 8 or 9. no changes in weight or eating were noted. no changes in concentration, suicidal ideation, and any suicidal history was denied. she denied symptoms of anxiety, although she did note that she thought he worried a little about going to school and some financial stress. other symptoms of psychopathology were denied.,developmental history: , the patient was reportedly a 7 pounds 12 ounces product of an unplanned and uncomplicated pregnancy and planned cesarean delivery. mother reported that she did receive prenatal care. the use of alcohol, drugs, or tobacco during the pregnancy were denied. she denied that he had any feeding or sleeping problems in the perinatal period. she described him as a fussy and active baby, but he was described as a cuddly baby. she noted that the pediatricians never expressed any concerns regarding his developmental milestones. she reported that he is allergic to penicillin. serious injures or toileting problems were denied as were a history of seizures.,family background: , the patient currently lives with his mother who is age 57 and with her partner who is age 40. they have been together since 1994, and he is the only father figure that the patient has even known. the father was previously in a relationship that resulted in an 11-year-old daughter who visits the patient's home every other weekend. the patient's father's whereabouts are unknown. there is no information on his family. mother stated that he discontinued his involvement in her life when she was about 3 months pregnant with the patient, and the patient has never met him. as noted, there is no information on the paternal side of the family. in terms of the mother's side of family, the maternal grandfather died in his 60s due to what mother described as "hardening of the arteries," and the maternal grandmother died in 2003 due to stroke. there were 4 maternal aunts, one of them died at age 9 months from pneumonia, one of them died at 19 years old from what was described as a brain tumor, and there are 3 maternal uncles. in terms of family relationships, it was reported that overall the patient tends to get along fairly well with his parents, who reported that the patient and her partner tend to compete for mother's attention, and she noted this is difficult at times. she reported that the patient and her partner do not really do anything together. mother reported that there is no domestic violence in the home, but there is some marital conflict, and this is may be difficult for the patient, as it is carried on in spanish, and he does not speak spanish. there also is some stress in the home due to the stepdaughter, as there are some concerns that her mother may be involved in drugs. the mother reported that she attended high school, did not attend any college. she denied learning problems. she denied psychological problems or any drug/alcohol history. in terms of the biological father, she reported he did not graduate from high school. she did not know of learning problems, psychological problems. she denied that he had a drug/alcohol history. there is a family history of alcoholism in one of the maternal uncles as well as in the maternal grandfather. it should be noted that the patient and his family live in a small 4-bedroom apartment, where privacy is very difficult.,social background:, she reported that the patient is able to make and keep friends, but he enjoys lifting weights, skateboarding, and that he recently had an opportunity to do rock climbing, he really enjoyed that. i encouraged her to have him involved in physical activity, as this is good for discharge the stress, to encourage the weightlifting, as well as the skateboarding. mother is going to check further information regarding the rock climbing that the patient had been involved in, which was at it sounds like by her description as some sort of boys' and girls' type of club. abuse of drugs or alcohol were denied. the patient was not described as being sexually active.,academic background: , the patient is currently in the 10th grade. at present, he is on independent studies, which began after his hospitalization. the mother reported that the teacher, who had come to school saw one of his episodes, and stated that, they would not want him to be attending school. i spoke with her very clearly and directly regarding the fact that it was probably not best for the patient to be on independent studies, that he needed to be returned to his normal school environment. he has never had an episode at school, and he needs to be back with his peers, back in a regular environment, where he is under normal expectations. i spoke with her regarding my concerns, regarding the fact that he is unsupervised during the day, and we do not want this turning into one big long vacation, where he is not getting his work done, and he gets himself in trouble. normally, he would be attending at high school. the mother stated that she would contact them as well as check into possibly a 504-plan. she reported that he really does not to go back to high school. he says, the "kids are bad;" however, she denied that he has any history of fighting. she noted that he is stressed by the school, there have been some peer problems, possibly some bullying. i noted these need to be addressed with the school, as she had not done so. she stated that she would speak with a counselor. she noted, however, that he has a history of not liking school and avoiding going to school. she noted that he is somewhat behind in his work due to the hospitalization. his grades traditionally are c's. she denied any special education services.,previous counseling: , denied.,diagnostic summary and impression: , similar to my impression at the hospital, it would appear that the patient clearly qualifies for a diagnosis of conversion disorder. it appears that there are multiple stressors in the family, and that the mother is reinforcing his conversion reaction. i am also very concerned regarding the fact that he is not attending school and want him back in the normal school environment as quickly as possible. my plan is to meet the patient at the next session to update the information regarding his functioning and to begin to teach him skills for reducing his stress and relaxing.,dsm-iv diagnoses: ,axis i: conversion disorder (300.11).,axis ii: no diagnosis (v71.09).,axis iii: no diagnosis.,axis iv: problems with primary support group, educational problems, and peer problems.,axis v: global assessment of functioning equals 60.

preoperative diagnosis:, left inguinal hernia.,postoperative diagnosis:, left direct and indirect inguinal hernia.,procedure performed:, repair of left inguinal hernia with prolene mesh.,anesthesia: , iv sedation with local.,complications:, none.,disposition: ,the patient tolerated the procedure well and was transferred to recovery in stable condition.,specimen: , hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac.,brief history: ,this is a 53-year-old male who presented to dr. y's office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months. the patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with prolene mesh.,intraoperative findings: , the patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac. the patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms.,procedure: , after informed consent, risks and benefits of the procedure were explained to the patient, the patient was brought to the operative suite, prepped and draped in the normal sterile fashion. the left inguinal ligament was identified from the pubic tubercle to the asis. two fingerbreadths above the pubic tubercle, a transverse incision was made. first, the skin was anesthetized with 1% lidocaine and then an incision was made with a #15 blade scalpel, approximately 6 cm in length. dissection was then carried down with electro bovie cautery through scarpa's fascia maintaining hemostasis. once the external oblique was identified, external oblique was incised in the length of its fibers with a #15 blade scalpel. metzenbaum scissors were then used to extend the incision in both directions opening up the external oblique down to the external ring. next, the external oblique was grasped with ochsner on both sides. the cord, cord structures as well as hernia sac were freed up circumferentially and a penrose drain was placed around it. next, the hernia sac was identified and the anteromedial portion of the hernia sac was stripped down, grasped with two hemostats. a metzenbaum scissor was then used to open the hernia sac and the hernia sac was explored. there was some turbid fluid within the hernia sac, which was sent down for cultures. gram stain was negative for organisms. next, the hernia sac was to be ligated at its base and transected. a peon was used at the base. metzenbaum scissor was used to cut the hernia sac and sending it off as a specimen. an #0 vicryl stick suture was used with #0 vicryl loop suture to suture ligate the hernia sac at its base.,next, attention was made to placing a prolene mesh to cover the floor. the mesh was sutured to the pubic tubercle medially along the ilioinguinal ligament inferiorly and along the conjoint tendon superiorly making a slit for the cord and cord structures. attention was made to salvaging the ilioinguinal nerve, which was left above the repair of the mesh and below the external oblique once closed and appeared to be intact. attention was next made after suturing the mesh with the #2-0 polydek suture. the external oblique was then closed over the roof with a running #0 vicryl suture, taking care not to strangulate the cord and to recreate the external ring. after injecting the external oblique and cord structures with marcaine for anesthetic, the scarpa's fascia was approximated with interrupted #3-0 vicryl sutures. the skin was closed with a running subcuticular #4-0 undyed vicryl suture. steri-strip with sterile dressings were applied.,the patient tolerated the procedure well and was transferred to recovery 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.,

name of procedure,1. left heart catheterization with left ventriculography and selective coronary angiography.,2. percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,history: , this is a 58-year-old male who presented with atypical chest discomfort. the patient had elevated troponins which were suggestive of a myocardial infarction. the patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,procedure details: , informed consent was given prior to the patient was brought to the catheterization laboratory. the patient was brought to the catheterization laboratory in postabsorptive state. the patient was prepped and draped in the usual sterile fashion, 2% xylocaine solution was used to anesthetize the right femoral region. using modified seldinger technique, a 6-french arterial sheath was placed. then, the patient had already been on heparin. then, a judkins left 4 catheter was intubated into the left main coronary artery. several projections were obtained and the catheter was removed. a 3drc catheter was intubated into the right coronary artery. several projections were obtained and the catheter was removed. then, a 3drc guiding catheter was intubated into the right coronary artery. then, a universal wire was advanced across the lesion into the distal right coronary artery. integrilin was given. then, a 3.0 x 12 voyager balloon was inflated at 13 atmospheres for 30 seconds. then, a projection was obtained. then, a 3.0 x 15 vision stent was placed into the distal right coronary artery. the stent was deployed at 15 atmospheres for 25 seconds. post stent, the patient was given intracoronary nitroglycerin after one projection. then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful. then, a pilot 150 wire was advanced across the lesion. then, attempt to place the 2.0 x 8 power saver across the lesion was performed. however, it was felt that there was adequate flow and no further intervention needed to be performed. then, the stent delivery system was removed. a pigtail catheter was placed into the left ventricle. hemodynamics followed by left ventriculography was performed. then, a pullback gradient was performed and the catheter was removed. then, the right femoral artery was visualized and using angiography and then an angio-seal was applied. the patient was transferred back to his room in good condition.,findings,1. hemodynamics: the opening aortic pressure was 116/61 with a mean of 64. the opening left ventricular pressure was 112 with end-diastolic pressure of 23. lv pressure on pullback was 106 with end-diastolic pressure of 21. aortic pressure was 111/67 with a mean of 87. the closing pressure was 110/67.,2. left ventriculography: the left ventricle was of normal cavity, size, and wall thickness. there is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis. the overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%. the mitral valve had no significant prolapse or regurgitation. the aortic valve appeared to be trileaflet and moved normally.,3. coronary angiography: the left main is a normal-caliber vessel. this bifurcates into the left anterior descending and circumflex arteries. the left main is free of any significant obstructive coronary artery disease. the left anterior descending is a large vessel that extends to the apex. it gives off approximately 10 septal perforators and 5 diagonal branches. the first diagonal branch was large. the left anterior descending had mild irregularities, but no high-grade disease. the left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches. the two obtuse marginal branches are large. there is a relatively small left atrial branch. the left circumflex had a 50% stenosis after the first obtuse marginal branch. the rest of the vessel is moderately irregular, but no high-grade disease. the right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches. the right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease. however, distal between the second and third posterolateral branch, there is a 90% stenosis. the rest of the vessels had mild irregularities, but no high-grade disease. then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis. then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch. then, a wire was advanced through this and there was improvement of flow. there is improvement from timi grade 2 to timi grade 3 flow.,clinical impression,1. successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2. two-vessel coronary artery disease.,3. elevated left ventricular end-diastolic pressure.,4. mild anterolateral and moderate inferoapical hypokinesis.,recommendations,1. integrilin.,2. bed rest.,3. risk factor modification.,4. thallium scintigraphy in approximately six weeks.

history: , the patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. the patient was then sent to hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. she was also noted to have periodic breathing. the patient is breast and bottle-fed and has been feeding well. there has been no diarrhea or vomiting. voiding well. bowels have been regular.,according to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of im ampicillin.,the patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat c-section. birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa. the patient's mother apparently went into labor and then underwent a cesarean section.,family history: , positive for asthma and diabetes and there is no exposure to second-hand smoke.,physical examination: , ,vital signs: the patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,general: the patient is icteric, well hydrated. does have periodic breathing. color is pink and also icterus is noted, scleral and skin.,heent: normal.,neck: supple.,chest: clear.,heart: regular with a soft 3/6 murmur. femorals are well palpable. cap refill is immediate,abdomen: soft, small, umbilical hernia is noted, which is reducible.,external genitalia: those of a female child.,skin: color icteric. nonspecific rash on the body, which is sparse. the patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,extremities: the patient moves all extremities well. has a normal tone and a good suck.,emergency department course: , it was indicated to the parents that i would be repeating labs and also catheterize urine specimen. parents were made aware of the fact that child did have a murmur. i spoke to dr. x, who suggested doing an ekg, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. the case was discussed with dr. y and he will be admitting this child for hyperbilirubinemia.,cbc done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. chemistries done showed sodium of 142 meq/l, potassium 4.5 meq/l, chloride 104 meq/l, co2 28 mmol/l, glucose 75 mg%, bun 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. total bilirubin was 25.4 mg, all of which was unconjugated. crp was 0.3 mg%. blood culture was drawn. catheterized urine specimen was normal. parents were kept abreast of what was going on all the time and the need for admission. phototherapy was instituted in the er almost after the baby got to the emergency room.,impression:, hyperbilirubinemia and heart murmur.,differential diagnoses: , considered breast milk, jaundice, abo incompatibility, galactosemia, and ventricular septal defect.

preoperative diagnosis:, ovarian cyst, persistent.,postoperative diagnosis: , ovarian cyst.,anesthesia:, general,name of operation:, diagnostic laparoscopy and drainage of cyst.,procedure:, the patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced. an infraumbilical incision was made, and veress needle placed without difficulty. gas was entered into the abdomen at two liters. the laparoscope was entered, and the abdomen was visualized. the second puncture site was made, and the second trocar placed without difficulty. the cyst was noted on the left, a 3-cm, ovarian cyst. this was needled, and a hole cut in it with the scissors. hemostasis was intact. instruments were removed. the patient was awakened and taken to the recovery room in good condition.

preoperative diagnoses:,1. bunion left foot.,2. hammertoe, left second toe.,postoperative diagnoses:,1. bunion left foot.,2. hammertoe, left second toe.,procedure performed:,1. bunionectomy, scarf type, with metatarsal osteotomy and internal screw fixation, left.,2. arthroplasty left second toe.,history: ,this 39-year-old female presents to abcd general hospital with the above chief complaint. the patient states that she has had bunion for many months. it has been progressively getting more painful at this time. the patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,procedure: , an iv was instituted by the department of anesthesia in the preop holding area. the patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. copious amount of webril were placed around the left ankle followed by a blood pressure cuff. after adequate sedation was achieved by the department of anesthesia, a total of 15 cc of 0.5% marcaine plain was injected in a mayo and digital block to the left foot. the foot was then prepped and draped in the usual sterile orthopedic fashion. the foot was elevated from the operating table and exsanguinated with an esmarch bandage. the pneumatic ankle tourniquet was inflated to 250 mmhg and the foot was lowered to the operating table. the stockinette was reflected. the foot was cleansed with wet and dry sponge. attention was then directed to the first metatarsophalangeal joint of the left foot. an incision was created over this area approximately 6 cm in length. the incision was deepened with a #15 blade. all vessels encountered were ligated for hemostasis. the skin and subcutaneous tissue was then dissected from the capsule. care was taken to preserve the neurovascular bundle. dorsal linear capsular incision was then created. the capsule was then reflected from the head of the first metatarsal. attention was then directed to the first interspace where a lateral release was performed. a combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. a lateral capsulotomy was performed. attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. the incision was then extended proximally with further dissection down to the level of the bone. two 0.45 k-wires were then inserted as access guides for the scarf osteotomy. a standard scarf osteotomy was then performed. the head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. after adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 k-wire. a 3.0 x 12 mm screw was then inserted in the standard ao fashion with compression noted. a second 3.0 x 14 mm screw was also inserted with tight compression noted. the remaining prominent medial eminence medially was then resected with a sagittal saw. reciprocating rasps were then used to smooth any sharp bony edges. the temporary fixation wires were then removed. the screws were again checked for tightness, which was noted. attention was directed to the medial capsule where a medial capsulorrhaphy was performed. a straight stat was used to assist in removing a portion of the capsule. the capsule was then reapproximated with #2-0 vicryl medially. dorsal capsule was then reapproximated with #3-0 vicryl in a running fashion. the subcutaneous closure was performed with #4-0 vicryl followed by running subcuticular stitch with #5-0 vicryl. the skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,attention was then directed to the left second toe. a dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. the incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. an incision was made on either side of the extensor digitorum longus tendon. a curved mosquito stat was then used to reflex the tendon laterally. the joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. a sagittal saw was then used to resect the head of the proximal head. the bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. the extensor digitorum longus tendon was inspected and noted to be intact. any sharp edges were then smoothed with reciprocating rasp. the area was then flushed with copious amounts of sterile saline. the skin was then reapproximated with #4-0 nylon. dressings consisted of owen silk, 4x4s, kling, kerlix, and coban. pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. the patient tolerated the above procedure and anesthesia well without complications. the patient was transported to pacu with vital signs stable and vascular status intact to the left foot. the patient is to follow up with dr. x in his clinic as directed.

cc: ,vertigo.,hx: ,this 61y/o rhf experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. in 11/92, while eating breakfast, she suddenly experienced vertigo. this was immediately followed by nausea and several episodes of vomiting. the vertigo lasted 2-3minutes. she retired to her room for a 2 hour nap after vomiting. when she awoke, the symptoms had resolved. on 1/13/93 she had an episode of right arm numbness lasting 4-5hours. there was no associated weakness, ha, dysarthria, dysphagia, visual change, vertigo or lightheadedness.,outside records:, 12/16/92 carotid doppler (rica 30-40%, lica 10-20%). 12/4/92, brain mri revealed a right cerebellar hypodensity consistent with infarct.,meds:, zantac 150mg bid, proventil mdi bid, azmacort mdi bid, doxycycline 100mg bid, premarin 0.625mg qd, provera 2.5mg qd. asa 325mg qd.,pmh:, 1)mdd off antidepressants since 6/92. 2)asthma. 3)allergic rhinitis. 4)chronic sinusitis. 5)s/p caldwell-luc 1978, and nasal polypectomy. 6) gerd. 7)h/o elevated tsh. 8)hypercholesterolemia 287 on 11/20/93. 9)h/o heme positive stool: be 11/24/92 and ugi 11/25/92 negative.,fhx: ,father died of a thoracic aortic aneurysm, age 71. mother died of stroke, age 81.,shx:, married. one son deceased. salesperson. denied tobacco/etoh/illicit drug use.,exam,: bp (rue)132/72 lue (136/76). hr67 rr16 afebrile. 59.2kg.,ms: a&o to person, place, time. speech fluent and without dysarthria. thought lucid.,cn: unremarkable.,motor: 5/5 strength throughout with normal muscle bulk and tone.,sensory: no deficits appreciated.,coord: unremarkable.,station: no pronator drift, truncal ataxia, or romberg sign.,gait: not done.,reflexes: 2/2 throughout bue and at patellae. 1/1 at achilles. plantar responses were flexor, bilaterally.,gen exam: obese.,course: ,cbc, gs, pt/ptt, ua were unremarkable. the patient was admitted with a working diagnosis of posterior circulation tia and history of cerebellar stroke. she was placed on ticlid 250mg bid. hct,1/15/93: low density focus in the right medial and posterior cerebellar hemisphere. mri and mra, 1/18/93, revealed a well circumscribed lesion within the posterior aspect of the right cerebellar hemisphere suggestive of vascular malformation (e.g. cavernous angioma. an abnormal vascular blush was seen on the mra. this area appeared to be supplied by one of the external carotid arteries (which one is was not specified). this finding maybe suggestive of a vascular malformation. 1/20/93 cerebral angiogram: the right cerebellar hemisphere lesion seen on mri as a possible cavernous angioma was not seen on angiography. upon review of the mri and hct the lesion was felt to probably represent an old infarction with hemosiderin deposition. the "vascular blush" seen on mra was no visualized on angiography. the patient was discharged home on 1/25/93.

procedure: , esophagogastroduodenoscopy with biopsy.,preoperative diagnosis: , a 1-year-10-month-old with a history of dysphagia to solids. the procedure was done to rule out organic disease.,postoperative diagnoses: , loose lower esophageal sphincter and duodenal ulcers.,consent: , the consent is signed.,medications: ,the procedure was done under general anesthesia given by dr. marino fernandez.,complications:, none.,procedure in detail:, a history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure. the opportunity for questions was provided, and informed consent was obtained. once the consent was obtained, the patient was sedated with iv medications and intubated by dr. fernandez and placed in the supine position. then, the tip of the xp-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus. we did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose. then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum. we noticed that the patient had several ulcers in the first portion of the duodenum. then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there. then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for clotest. by retroflexed view, at the level of the body of the stomach, i could see that the patient had the lower esophageal sphincter loose. finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken. at the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth. the patient tolerated the procedure well with no complications.,final impression: ,1. duodenal ulcers.,2. loose lower esophageal sphincter.,plan:,1. to start omeprazole 20 mg a day.,2. to review the biopsies.,3. to return the patient back to clinic in 1 to 2 weeks.

chief complaint:, diarrhea, vomiting, and abdominal pain.,history of present illness:, the patient is an 85-year-old female who presents with a chief complaint as described above. the patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. she was found by ems sitting on the toilet having diarrhea, and apparently had also just vomited. upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. she cannot tell me how many times. she is also unable to describe the vomitus. she also tells me that her belly has been hurting. i am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,past medical history:, per the er documentation is hypertension, diverticulosis, blindness, and sciatica.,medications:, lorazepam 0.5 mg, dosing interval is not noted; tylenol pm; klor-con 10 meq; lexapro; calcium with vitamin d.,allergies:, she is allergic to penicillin.,family history:, unknown.,social history:, also unknown.,review of systems:, unobtainable secondary to the patient's condition.,physical examination:,vital signs: pulse 80. respiratory rate 18. blood pressure 130/80. temperature 97.6.,general: elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,neck: no jvd. no thyromegaly.,ears, nose, and throat: her oropharynx is dry. her hearing is very diminished.,cardiovascular: regular rhythm. no lower extremity edema.,gi: mild epigastric tenderness to palpation without guarding or rebound. bowel sounds are normoactive.,respiratory: clear to auscultation bilaterally with a normal effort.,skin: warm, dry, no erythema.,neurological: the patient attempts to answer questions when asked, but is very hard of hearing. she is seen to move all extremities spontaneously.,diagnostic data:, white count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, ptt 24, pt 13.3, inr 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, bun 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, ast 33, alt 26, alkaline phosphatase 92. cardiac isoenzymes negative x1. ekg shows sinus rhythm with a rate of 96 and a prolonged qt interval.,assessment and plan:,1. pancreatitis. will treat symptomatically with morphine and zofran, and also iv fluids. will keep npo.,2. diarrhea. will check stool studies.,3. volume depletion. iv fluids.,4. hyperglycemia. it is unknown whether the patient is diabetic. i will treat her with sliding scale insulin.,5. hypertension. if the patient takes blood pressure medications, it is not listed on the only medication listing that is available. i will prescribe clonidine as needed.,6. renal failure. her baseline is unknown. this is at least partly prerenal. will replace volume with iv fluids and monitor her renal function.,7. hypokalemia. will replace per protocol.,8. hypercalcemia. this is actually rather severe when adjusted for the patient's low albumin. her true calcium level comes out to somewhere around 12. for now, i will just treat her with iv fluids and lasix, and monitor her calcium level.,9. protein gap. this, in combination with the calcium, may be suggestive of multiple myeloma. it is my understanding that the family is seeking hospice placement for the patient right now. i would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.

chief complaint: , "a lot has been thrown at me.",the patient is interviewed with husband in room.,history of present illness: , this is a 69-year-old caucasian woman with a history of huntington disease, who presented to hospital four days ago after an overdose of about 30 haldol tablets 5 mg each and tylenol tablet 325 mg each, 40 tablets. she has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today. the patient states she had been thinking about suicide for a couple of weeks. felt that her huntington disease had worsened and she wanted to spare her family and husband from trouble. reports she has been not socializing with her family because of her worsening depression. husband notes that on monday after speaking to dr. x, they had been advised to alternate the patient's pamelor (nortriptyline) to every other day because the patient was reporting dry mouth. they did as they have instructed and husband feels this may have had some factor on her worsening depression. the patient decided to ingest the pills when her husband went to work on friday. she thought friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened. her husband left around 7 in the morning and returned around 11 and found her sleeping. about 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,she says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the huntington gene. she does not clearly explain how this has made her suicidality subside.,this is the third suicide attempt in the last two months for this patient. about two months ago, the patient took an overdose of tylenol and some other medication, which the husband and the patient are not able to recall. she was taken to southwest memorial hermann hospital. a few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor. husband locked the gun after that and she was taken to bellaire hospital. the patient has had three psychiatric admissions in the past two months, two to southwest memorial and one to bellaire hospital for 10 days. she sees dr. x once or twice weekly. he started seeing her after her first suicide attempt.,the patient's husband and the patient state that until march 2009, the patient was independent, was driving herself around and was socially active. since then she has had worsening of her huntington symptoms including short-term memory loss. at present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath. the patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her huntington disease.,the patient's mother passed away 25 years ago from huntington's. her grandmother passed away 50 years ago and two brothers also passed away of huntington's. the patient has told her husband that she does not want to go that way. the patient denies auditory or visual hallucinations, denies paranoid ideation. the husband and the patient deny any history of manic or hypomanic symptoms in the past.,past psychiatric history: , as per the hpi, this is her third suicide attempt in the last two months and started seeing dr. x. she has a remote history of being on lexapro for depression.,medications: , her medications on admission, alprazolam 0.5 mg p.o. b.i.d., artane 2 mg p.o. b.i.d., haldol 2.5 mg p.o. t.i.d., norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily. husband has stated that the patient's chorea becomes better when she takes haldol. alprazolam helps her with anxiety symptoms.,past medical history: , huntington disease, symptoms of dementia and hypertension. she has an upcoming appointment with the neurologist. currently, does have a primary care physician and _______ having an outpatient psychiatrist, dr. x, and her current neurologist, dr. y.,allergies: , codeine and keflex.,family medical history: ,strong family history for huntington disease as per the hpi. mother and grandmother died of huntington disease. two young brothers also had huntington disease.,family psychiatric history: , the patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,social history: ,the patient lives with her husband of 48 years. she used to be employed as a registered nurse. her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. she rarely drinks socially. she denies any illicit substance usage. her husband reportedly gives her medication daily. has been proactive in terms of seeking mental health care and medical care. the patient and husband report that from march 2009, she has been relatively independent, more socially active.,mental status exam: ,this is an elderly woman appearing stated age. alert and oriented x4 with poor eye contact. appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips. she is cooperative. her speech is of low volume and slow rate and rhythm. her mood is sad. her affect is constricted. her thought process is logical and goal-directed. her thought content is negative for current suicidal ideation. no homicidal ideation. no auditory or visual hallucinations. no command auditory hallucinations. no paranoia. insight and judgment are fair and intact.,laboratory data:, a ct of the brain without contrast, without any definite evidence of acute intracranial abnormality. u-tox positive for amphetamines and tricyclic antidepressants. acetaminophen level 206.7, alcohol level 0. the patient had a leukocytosis with white blood cell of 15.51, initially tsh 1.67, t4 10.4.,assessment: , this is a 69-year-old white woman with huntington disease, who presents with the third suicide attempt in the past two months. she took 30 tablets of haldol and 40 tablets of tylenol. at present, the patient is without suicidal ideation. she reports that her worsening depression has coincided with her worsening huntington disease. she is more hopeful today, feels that she may be able to get help with her depression.,the patient was admitted four days ago to the medical floor and has subsequently been stabilized. her liver function tests are within normal limits.,axis i: major depressive disorder due to huntington disease, severe. cognitive disorder, nos.,axis ii: deferred.,axis iii: hypertension, huntington disease, status post overdose.,axis iv: chronic medical illness.,axis v: 30.,plan,1. safety. the patient would be admitted on a voluntary basis to main-7 north. she will be placed on every 15-minute checks with suicidal precautions.,2. primary psychiatric issues/medical issues. the patient will be restarted as per written by the consult service for prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, haldol 2 mg p.o. q.8h., artane 2 mg p.o. daily, xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3. substance abuse. no acute concern for alcohol or benzo withdrawal.,4. psychosocial. team will update and involve family as necessary.,disposition: , the patient will be admitted for evaluation, observation, treatment. she will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy. we will place occupational therapy consult and social work consults.

preoperative diagnoses:,1. squamous cell carcinoma of the head and neck.,2. ethanol and alcohol abuse.,postoperative diagnoses:,1. squamous cell carcinoma of the head and neck.,2. ethanol and alcohol abuse.,procedure:,1. failed percutaneous endoscopic gastrostomy tube placement.,2. open stamm gastrotomy tube.,3. lysis of adhesions.,4. closure of incidental colotomy.,anesthesia:, general endotracheal anesthesia.,iv fluids:, crystalloid 1400 ml.,estimated blood loss:, thirty ml.,drains:, gastrostomy tube was placed to foley.,specimens:, none.,findings:, stomach located high in the peritoneal cavity. multiple adhesions around the stomach to the diaphragm and liver.,history: ,the patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. he presented initially to the emergency room with throat and bleeding. following evaluation by ent and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, the patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. the malignancy was not obstructing. following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,description of procedure:, the patient was placed in the supine position and general endotracheal anesthesia was induced. preoperatively, 1 gram of ancef was given. the abdomen was prepped and draped in the usual sterile fashion. after anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. the stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. with the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. a 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. both times it was not visualized on the endoscopy. at this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. at this point, decision was made to convert the procedure to an open stamm gastrostomy.,open stamm gastrostomy: ,a short upper midline incision was made and deepened through the subcutaneous tissues. hemostasis was achieved with electrocautery. the linea alba was identified and incised, and the peritoneal cavity was entered. the abdomen was explored. adhesions were lysed with electrocautery under direct vision. the stomach was identified, and a location on the anterior wall near the greater curvature was selected. after lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. a pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. an incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. a vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the bard feeding tube through the anterior wall into the field. an incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. the interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. the second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. the stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. the catheter was then secured to the skin with two #2-0 silk sutures. hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. this was oversewn with three #4-0 silk lembert sutures. at the completion of the operation, the fascia was closed with #1 interrupted vicryl suture, and the skin was closed with staples. the patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.

preoperative diagnosis,subglottic upper tracheal stenosis.,postoperative diagnosis,subglottic upper tracheal stenosis.,operation preformed,direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,indications for the surgery,the patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis. she has had undergone multiple previous endoscopic procedures in the past; last procedure was in january 2007. she returns with some increasing shortness of breath and dyspnea on exertion. endoscopic reevaluation is offered to her. the patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms. an endoscopic treatment was offered to her. nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length. the patient states she understood and wished to proceed.,description of the operation,the patient was taken to the operating room, placed on table in supine position. following adequate general anesthesia, the patient was prepared for endoscopy. the top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. in the oral cavity, she had good dentition. tongue and buccal cavity mucosa were without ulcers, masses, or lesions. the oropharynx was clear. the larynx was then manually suspended. epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent. the larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds. at the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred. moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated. remainder of the bronchi was then examined. the mid and distal trachea were widely patent. pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring. the scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out. once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished. instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia. the patient tolerated the procedure well without complication.

reason for consultation:, renal failure evaluation for possible dialysis therapy.,history of present illness:, this is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally. he also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids. while he was there, he was drinking cranberry juice, some powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now. he presented here with very decreased urine output until a foley catheter was placed and about 500 ml was noted in his bladder. he did have a cpk level of about 234 while his bun and creatinine on admission were 109 and 6.9. despite iv hydration fluids, his potassium has gone up from 5.4 to 6.1. he did not put out any significant urine and his weight was documented at 103 kg. he was given a dose of kayexalate. his potassium came down to like about 5.9 and urine studies were ordered. his urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria. he did have a low albumin of 1.9. he denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems. he has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care. he is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired. he denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain. he did have a decrease in his appetite, which all started about thursday. we were asked to see this patient in consultation by dr. x because of his renal failure and the need for possible dialysis therapy. he was significantly hypertensive on admission with a blood pressure of 162/80.,past medical history: , unremarkable.,past surgical history: , unremarkable.,family history: , both mother and father were on dialysis of end-stage renal disease.,social history: , he is married. he does smoke despite understanding the risks associated with smoking a pack every 6 days. does not drink alcohol or use any recreational drug use. he was on no prescribed medications. he did have a fairly normal psa of about 119 and i had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,physical examination:,vital signs: blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,general: he was alert and oriented x 3, in no apparent distress, well-developed male.,heent: normocephalic, atraumatic. pupils are equal, round, and reactive to light. extraocular muscles intact.,neck: supple. no jvd, adenopathy, or bruit.,chest: clear to auscultation.,heart: regular rate and rhythm without a rub.,abdomen: soft, nontender, nondistended. positive bowel sounds.,extremities: showed no clubbing, cyanosis. he did have 2+ pretibial edema in both lower extremities.,neurologic: no gross focal findings.,skin: showed no active skin lesions.,laboratory data: , sodium 138, potassium 6.1, chloride 108, co2 22, glucose 116, bun 111, creatinine 7.29, estimated gfr 10 ml/minute. calcium 7.4 with an albumin of 1.9. mag normal at 2.2. urine culture negative at 12 hours. his random urine sodium was low at 12. random urine protein was 4756, and creatinine in the urine was 538. urine drug screen was unremarkable. troponin was within normal limits. phosphorus slightly elevated at 5.7. cpk level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs. pt 10.0, inr 1.0, ptt at 27.3. b-natriuretic peptide 718. urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,impression:,1. acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to iv fluids.,2. hyperkalemia due to renal failure, slowly improving with kayexalate.,3. microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4. hypertension.,plan: , i will give him kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2. i will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to abcd center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable. we will get a bmp, phosphorus, mag, cbc in the morning since he was given 80 mg of lasix for fluid retention. we will also give him 10 mg of zaroxolyn p.o. discontinue all iv fluids. check an anca hepatitis profile, c3 and c4 complement levels along with ch 50 level. i did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job. i do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,i appreciate consult. i did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.

preoperative diagnosis:, cataract, right eye.,postoperative diagnosis:, cataract, right eye.,operation performed: , phacoemulsification with iol, right eye.,anesthesia:, topical with mac.,complications,: none.,estimated blood loss: , none.,procedure in detail: after appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per ophthalmology. a lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free xylocaine was injected followed by viscoat. a 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and utrata. bss on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification i&a. healon was injected into the posterior capsule and a xxx lens was then placed with a shooter into the posterior capsule and rotated into position with i&a, which then removed all remaining cortex as well as viscoelastic material. bss on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed. under microscope, the anterior chamber being soft and well formed. pred forte, vigamox, and iopidine were placed in the eye. a shield was placed over the eye. the patient was followed to recovery where he was noted to be in good condition.

procedure: ,trigger thumb release.,procedure in detail: , after administering appropriate antibiotics and mac anesthesia, the upper extremity was prepped and draped in the usual sterile fashion. the arm was exsanguinated with esmarch, and the tourniquet inflated to 250 mmhg.,a transverse incision was made over the mpj crease of the thumb. dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles. the flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the a1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx. meticulous hemostasis was maintained with bipolar electrocautery.,the flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained. the patient then actively moved the thumb and no triggering was noted.,after irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,the wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.

history: , a 59-year-old male presents in followup after being evaluated and treated as an in-patient by dr. x for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008. please refer to chart for history and physical and review of systems and medical record.,procedures performed: ,fiberoptic laryngoscopy identifying about 30% positive muller maneuver. no supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,impression: ,1. resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2. possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3. hypercholesterolemia.,4. history of anxiety.,5. history of coronary artery disease.,6. hypertension.,recommendations: , recommend continuing on augmentin and tapered prednisone as prescribed by dr. x. cultures are still pending and follow up with dr. x in the next few weeks for re-evaluation. i did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with dr. x on his followup, and he will pay more attention on his sleep pattern.

cardiolite treadmill exercise stress test,clinical data:, this is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,procedure:, the patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 mets. there was a normal blood pressure response. the patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,myocardial perfusion imaging was performed at rest following the injection of 10 mci tc-99 cardiolite. at peak pharmacological effect, the patient was injected with 30 mci tc-99 cardiolite.,gating poststress tomographic imaging was performed 30 minutes after the stress.,findings:,1. the overall quality of the study is fair.,2. the left ventricular cavity appears to be normal on the rest and stress studies.,3. spect images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4. the left ventricular ejection fraction was normal and estimated to be 78%.,impression: , myocardial perfusion imaging is normal. result of this test suggests low probability for significant coronary artery disease.

title of operation:,1. diagnostic arthroscopy exam under anesthesia, left shoulder.,2. debridement of chondral injury, left shoulder.,3. debridement, superior glenoid, left shoulder.,4. arthrotomy.,5. bankart lesion repair.,6. capsular shift, left shoulder (mitek suture anchors; absorbable anchors with nonabsorbable sutures).,indication for surgery: , the patient was seen multiple times preoperatively and found to have chronic instability of her shoulder. risks and benefits of the procedure had been discussed in length including but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, continued instability, recurrent instability, medical complications, surgical complications, and anesthesia complications. the patient understood and wishes to proceed.,preop diagnosis: , anterior instability, left shoulder.,postop diagnoses:,1. anterior instability, left shoulder.,2. grade 4 chondromalacia, 10% humeral head, chondral defect 1 cm squared, left shoulder.,3. type 1 superior labrum anterior and posterior lesion, left shoulder.,4. anteroinferior glenoid erosions 10% bony surface, left shoulder.,5. bankart lesion, left shoulder.,procedure: , the patient was placed in a supine position and both shoulders examined systematically. she had full range of motion with no joint adhesions. she had equal range of motion bilaterally. she had hawkins 2 anteriorly and posteriorly in both shoulders with a grade 1 sulcus sign in both shoulders. this was the same when the arm was in neutral or in external rotation. the patient was then turned to right lateral decubitus position, axillary roll was placed, and beanbag was inflated. peroneal nerve was well protected. all bony prominences were well protected.,the left upper extremity was then prepped and draped in the usual sterile fashion. the patient was given antibiotics well before the start of the procedure to decrease the risk of infection. the arm was placed in a arm holder with 10 pounds of traction. a posterior portal was created in the usual manner by isolating gently with the spinal needle, it was insufflated with 30 cubic centimeters of saline. a small incision was made after infiltrating the skin with marcaine and epinephrine. the scope was introduced into the shoulder with no difficulty. it was then examined systematically. the patient did have diffuse synovitis throughout her shoulder. her posterior humeral head showed an enlarged bold spot with some other areas of chondromalacia on the posterior head. she also had an area 1 cm in diameter, which was on more central portion of the head and more inferiorly which appeared to be more of an impaction-type injury. this had some portions of fibrillated and loose cartilage, hanging from the edges. these were later debrided, but the dissection was proximally 10 to 15% of the humeral surface.,the biceps tendon appeared to be normal. the supraspinatus, infraspinatus tendons were normal. the inferior pouch was normal with no capsular tearing and no hagl lesions. the posteroinferior labrum was normal as well as the posterosuperior labrum. there was some fraying in the posterosuperior labrum, which was later debrided. it was found essentially to be a type 1 lesion anteriorly and superiorly. the anterosuperior labrum appeared to be detached, which appeared to be more consistent with a sublabral hole. the middle glenohumeral ligament was present as an entire sheath, but attach to the labrum. the labrum did appeared to be detached from the anterior glenoid from the 11 o'clock position all the way down to the 6 o'clock position. the biceps anchor itself was later probed and found to be stable and normal. the subscapularis tendon was normal. the anterior band of the glenohumeral ligament was present, but it was clearly avulsed off the glenoid. there was some suggestion of anteroinferior bony erosions, which was later substantiated when the shoulder was opened. the patient was missing about 10 to 15% of her anteroinferior glenoid rim. the patient had a positive drive-through sign.,the arm was then moved to lateral and placed through range of motion. there was contact of the rotator cuff to the superior glenoid in flexion at 115 degrees, maximum flexion was 150 degrees. the arm abducted and externally rotated. there was contact to the rotator cuff with posterosuperior labrum. this occurred with the arm position of 90 degrees with abduction at 55 degrees of external rotation. it should be noted that the maximum abduction is 150 degrees and with the arm abducted 90 degrees, maximum external rotation was 95 degrees. the patient did have a positive relocation maneuver. the posterior labrum did appear to tilt-off, but did not appear to peel off.,the arm was then placed back in the arm holder. anterior portal was created with wissinger rod. a blue cannula was inserted into the shoulder without difficulty. shaver was introduced in the labrum. also the area of chondromalacia as mentioned above was debrided. the labrum was found to be stable with only a type 1 slap lesion, and there was no evidence as there was really a type 2 slap lesion. the instruments were then removed along with excess fluid. the posterior portals were closed with single 4-0 nylon suture. the anterior portal was left open. the patient was then placed in a supine position, and the extremity was reprepped and draped in anticipation of performing open capsular shift.,the patient's anterior incision made just lateral to the coracoid in the skin line. mediolateral skin flaps were developed, and cephalic vein was identified and protected throughout the case. the interval was developed down the clavipectoral fascia. the conjoined tendon was retracted medially and the deltoid laterally. the patient's subscapularis was intact, and the subscapularis split was then made between the upper one half and lower one half in line with muscle fibers. the capsule could easily be detached from the muscle, and the interval developed very easily. a retractor was placed inferiorly to protect the axillary nerve. then gelpi retractor was used to hold the subscapularis split open.,next, an arthrotomy was made down at the 9 o'clock position. the labrum was identified and found to be attached all the way down to 6 o'clock position. the inferior flap was then created in a usual manner and tied with a 0 vicryl suture. the patient's glenoid rim did have some erosion as mentioned above with some bone loss and flattening. this was debrided with the soft tissue. three mitek suture anchors were then placed into the glenoid rim right at the margin of articular cartilage to the scapular neck. these were absorbable anchors with nonabsorbable sutures. they had excellent fixation once they had been placed.,next, the capsular shift and bankart repair were performed in the usual manner with the number 2 ti-cron sutures as an outside in and then inside out technique. this brought the capsule right up to the edge of the glenoid rim. with the arm in internal rotation and posterior pressure on the head, the capsule was then secured to the rim with no difficulty under direct visualization. the capsule did come right up into the joint as expected with this type of repair. the superior flap was then closed, the inferior flap over the superior anchor. the interval between two flaps was closed with multiple number 2 ti-cron sutures. once this has been completed, there was no tension on the repair with the arm to side until 10 degrees of external rotation was reached. the arm abducted 90 degrees. there was tension on the repair until 20 degrees of external rotation reached.,the wound was thoroughly irrigated throughout with antibiotic-impregnated irrigation. the subscapularis split was closed with interrupted 0 vicryl sutures. the deep subcutaneous tissues were closed with interrupted 0 vicryl sutures. the superficial subcutaneous tissues were closed with number 2-0 vicryl sutures. the skin was closed with 4-0 subcuticular prolene, reinforced with steri-strips. a sterile bandage was applied along with a cold therapy device and a shoulder immobilizer. the patient was sent to the recovery room in stable and satisfactory condition.

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

thereafter, he was evaluated and it was felt that further reconstruction as related to the anterior cruciate ligament was definitely not indicated. on december 5, 2008, mr. xxxx did undergo a total knee replacement arthroplasty performed by dr. x.,thereafter, he did an extensive course of physical therapy, work hardening, and a work conditioning type program.,at the present time, he does complain of significant pain and swelling as related to the right knee. he is unable to crawl and/or kneel. he does state he is able to walk a city block and in fact, he is able to do 20 minutes of a treadmill. stairs are a significant problem. his pain is a 5 to 6 on a scale of 1 to 10.,he is better when he is resting, sitting, propped up, and utilizing his ice. he is much worse when he is doing any type of physical activity.,he has denied having any previous history of similar problems.,current medications: ,over-the-counter pain medication.,allergies: , nka.,surgeries: , numerous surgeries as related to the right lower extremity.,social history: , he does admit to one half pack of cigarette consumption per day. he denies any alcohol consumption.,physical examination: ,on examination today, he is 28-year-old male who is 6 feet 1, weighs 250 pounds. he does not appear to be in distress at this time. one could appreciate 1-2/4 intraarticular effusion. the range of motion is 0 to a 110 degrees of flexion. i could not appreciate any evidence of instability medial, lateral, anterior or posterior. crepitus is noted with regards to range of motion testing. his strength is 4 to 5 as related to the quadriceps and hamstring.,there is atrophy as related to the right thigh. the patient is able to stand from a seated position and sit from a standing position without difficulty.,records review:,1. first report of injury.,2. july 17, 2002, x-rays of the right knee were negative.,3. notes of the medina general hospital occupational health, steven rodgers, m.d.,4. august 5, 2002, an mri scan of the right knee which demonstrated peripheral tear of the posterior horn of the medial

preoperative diagnosis: , nasal deformity, status post rhinoplasty.,postoperative diagnosis: , same.,procedure:, revision rhinoplasty (cpt 30450). left conchal cartilage harvest (cpt 21235).,anesthesia: , general.,indications for the procedure: , this patient is an otherwise healthy male who had a previous nasal fracture. during his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma. the patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect. the patient was consented for the above-stated procedure. the risks, benefits, and alternatives were discussed.,description of procedure: ,the patient was prepped and draped in the usual sterile fashion. the patient did have approximately 12 ml of lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues. in addition to this, cocaine pledgets were placed to assist with hemostasis.,at this point, attention was turned to the left ear. approximately 3 ml of 1% lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb. betadine was utilized for preparation. a 15 blade was used to incise along the posterior conchal area and a freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane. i then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested. these were placed aside in saline. hemostasis was obtained with bipolar electrocauterization. bovie electrocauterization was also employed as needed. the entire length of the wound was then closed with 5-0 plain running locking suture. the patient then had a telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 prolene suture. antibiotic ointment was applied generously.,next, attention was turned to opening and lifting the soft tissues of the nose. a typical external columella inverted v gull-wing incision was placed on the columella and trailed into a marginal incision. the soft tissues of the nose were then elevated using curved sharp scissors and metzenbaums. soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum. at this point, attention was turned to osteotomies and examination of the external cartilages.,the patient did have very broad lower lateral cartilages leading to a bulbous tip. the lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect. having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome. these were done transmucosally after elevating the tract using a cottle elevator. direct hemostasis pressure was applied to assist with bruising.,next, attention was turned to tip mechanisms. the patient had a series of double-dome sutures placed into the nasal tip. then, 5-0 dexon was employed for intradomal suturing, 5-0 clear prolene was used for interdomal suturing. having completed this, a 5-0 clear prolene alar spanning suture was employed to narrow the superior tip area.,next, attention was turned to dorsal augmentation. a gore-tex small implant had been selected, previously incised. this was taken to the back table and carved under sterile conditions. the patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum. it was placed into a precise pocket and remained in the midline.,next, attention was turned to performing a columella strut. the cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage. this was fixed into position utilizing a 5-0 dexon suture.,having completed placement of all augmentation grafts, the patient was examined for hemostasis. the external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures. the entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,at the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic. there was no evidence of hematoma, and the patient had a series of brown steri-strips and aquaplast cast placed over the nasal dorsum. the inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,the patient was transferred to the pacu in stable condition. he was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the gore-tex implant area. he was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.

preoperative diagnoses:,1. bunion left foot.,2. hammertoe, left second toe.,postoperative diagnoses:,1. bunion left foot.,2. hammertoe, left second toe.,procedure performed:,1. bunionectomy, scarf type, with metatarsal osteotomy and internal screw fixation, left.,2. arthroplasty left second toe.,history: ,this 39-year-old female presents to abcd general hospital with the above chief complaint. the patient states that she has had bunion for many months. it has been progressively getting more painful at this time. the patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,procedure: , an iv was instituted by the department of anesthesia in the preop holding area. the patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap. copious amount of webril were placed around the left ankle followed by a blood pressure cuff. after adequate sedation was achieved by the department of anesthesia, a total of 15 cc of 0.5% marcaine plain was injected in a mayo and digital block to the left foot. the foot was then prepped and draped in the usual sterile orthopedic fashion. the foot was elevated from the operating table and exsanguinated with an esmarch bandage. the pneumatic ankle tourniquet was inflated to 250 mmhg and the foot was lowered to the operating table. the stockinette was reflected. the foot was cleansed with wet and dry sponge. attention was then directed to the first metatarsophalangeal joint of the left foot. an incision was created over this area approximately 6 cm in length. the incision was deepened with a #15 blade. all vessels encountered were ligated for hemostasis. the skin and subcutaneous tissue was then dissected from the capsule. care was taken to preserve the neurovascular bundle. dorsal linear capsular incision was then created. the capsule was then reflected from the head of the first metatarsal. attention was then directed to the first interspace where a lateral release was performed. a combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected. a lateral capsulotomy was performed. attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence. the incision was then extended proximally with further dissection down to the level of the bone. two 0.45 k-wires were then inserted as access guides for the scarf osteotomy. a standard scarf osteotomy was then performed. the head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle. after adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 k-wire. a 3.0 x 12 mm screw was then inserted in the standard ao fashion with compression noted. a second 3.0 x 14 mm screw was also inserted with tight compression noted. the remaining prominent medial eminence medially was then resected with a sagittal saw. reciprocating rasps were then used to smooth any sharp bony edges. the temporary fixation wires were then removed. the screws were again checked for tightness, which was noted. attention was directed to the medial capsule where a medial capsulorrhaphy was performed. a straight stat was used to assist in removing a portion of the capsule. the capsule was then reapproximated with #2-0 vicryl medially. dorsal capsule was then reapproximated with #3-0 vicryl in a running fashion. the subcutaneous closure was performed with #4-0 vicryl followed by running subcuticular stitch with #5-0 vicryl. the skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,attention was then directed to the left second toe. a dorsal linear incision was then created over the proximal phalangeal joint of the left second toe. the incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally. an incision was made on either side of the extensor digitorum longus tendon. a curved mosquito stat was then used to reflex the tendon laterally. the joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx. a sagittal saw was then used to resect the head of the proximal head. the bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto. the extensor digitorum longus tendon was inspected and noted to be intact. any sharp edges were then smoothed with reciprocating rasp. the area was then flushed with copious amounts of sterile saline. the skin was then reapproximated with #4-0 nylon. dressings consisted of owen silk, 4x4s, kling, kerlix, and coban. pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot. the patient tolerated the above procedure and anesthesia well without complications. the patient was transported to pacu with vital signs stable and vascular status intact to the left foot. the patient is to follow up with dr. x in his clinic as directed.